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Full text of "Extent and adequacy of insurance coverage for substance abuse services"

National Institute on Drug Abuse 



No. 2 



I 



Services Research 
Series 



Extent and Adequacy of 
Insurance Coverage for 
Substance Abuse Services 

Institute of Medicine Report: 
Treating Drug Problems 



Volume I 



U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Alcohol, Drug Abuse, and Mental Health Administration 



51 



U.S. Department of Health and Human Services 

Louis W. Sullivan, M.D., Secretary 

Alcohol, Drug Abuse, and Mental Health Administration 

Frederick K. Goodwin, M.D., Administrator 

National Institute on Drug Abuse (NIDA) 

Charles R. Schuster, Ph.D., Director 

Division of Applied Research (DAR) 

Joseph H. Autry III, M.D., Director 

Executive Editor, Drug Abuse Services Research Series 

James M. Kaple, Ph.D., Associate Director 
For Services Research, DAR, NIDA 

Managing Editor, Drug Abuse Services Research Series 

Beatrice A. Rouse, Ph.D. 

Financing & Services Research Branch, DAR, NIDA 



Drug Abuse Services Research Series 




Extent and Adequacy of Insurance 
Coverage for Substance Abuse Services 

(Institute of Medicine Report: Treating Drug Problems) 



Volume 1 

A Study of the Evolution, Effectiveness, and Financing 
of Public and Private Drug Treatment Systems 



^ 
.^ 






U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Alcohol, Drug Abuse, and Mental Health Administration 

National Institute on Drug Abuse 
Division of Applied Research 
Financing and Services Research Branch 
5600 Fishers Lane 
Rockville, MD 20857 




ABUSE SERVICES RESEARCH SERIES 



The Drug Abuse Services Research Series is issued by the National Institute on Drug Abuse's 
Financing and Services Research Branch within the Division of Applied Research. The 
National Institute on Drug Abuse (NIDA) is the Federal agency with primary responsibility 
for research on drug abuse. Such research includes the biological, pharmacological, 
psychological, and sociocultural aspects of drug abuse. 

NIDA's Financing and Services Research Branch is responsible for coordinating and 
conducting research, demonstration, and evaluation studies on the capacity, efficiency, 
effectiveness, organization, structure, and financing of drug abuse treatment programs and 
delivery systems. The Drug Abuse Services Research Series disseminates the latest drug 
abuse services research on a range of topics, including quality of care, financing, and cost- 
effectiveness. 

NIDA wishes to express its appreciation to the many members of the scientific and treatment 
community who reviewed this report as well as to its authors. 



The views and opinions expressed in this issue are solely those of the authors and do not 
necessarily constitute an endorsement, real or implied, by the National Institute on Drug 
Abuse or any other part of the U.S. Department of Health and Human Services. 



ACKNOWLEDGMENT 

This issue of the Drug Abuse Services Research Series is a reprint of the first volume of the 
Institute of Medicine's Substance Abuse Coverage Study, conducted under NIDA Contract No. 
283-88-0009 (SA) and published as Treating Drug Problems, Volume 1 by the National Academy 
Press. 



COPYRIGHT STATUS 

The National Institute on Drug Abuse has obtained permission from copyright holders to 
reproduce certain previously published material as noted in the text in this issue. All 
material in this issue except quoted passages from copyrighted sources is in the public 
domain and may be used or reproduced without permission from the Institute or the 
authors. Citation of the source is appreciated. 



DHHS Publication Number (ADM) 92-1778 
Printed 1992 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



CONTENTS 

Page 

FOREWORD vii 

COMMITTEE FOR THE SUBSTANCE ABUSE COVERAGE STUDY viii 

PREFACE ix 

SUMMARY 1 

Questions the Report Answers and Those It Leaves Unresolved 1 

Ideas Governing Drug Treatment Policy 2 

Drug Problems and the Need For Drug Treatment 3 

Patterns of Drug Consumption 3; Dependence 3; Recovery and Relapse 4; 

Determining the Need for Treatment 5; 

Estimating the Aggregate Need for Treatment 5; 
The Goals of Drug Treatment 6 

Motivations for Treatment 6; Treatment and Criminal Justice 7; 
The Effectiveness of Treatment 7; 

Methadone Maintenance 8; Therapeutic Communities 10; 

Outpatient Nonmethadone Programs 10; Chemical Dependency Programs 11; 

Detoxification 1 1 ; Variations in Effectiveness of Programs Within Modalities 1 1 ; 

Treatment in Prisons 12; Costs and Benefits of Treatment 12; 

Comparison of Data on Effectiveness and Expenditures for the Major 
Treatment Modalities 12; 

Needs and Priorities for Research on Treatment Methods and Services 13 
The Two-Tiered Structure of the Treatment System 15 
Public Financing of Drug Treatment 16 

The Goals and Priorities of Public Coverage 16; Federal and State Roles 17; 

Mechanisms for Providing Public Support 18; Utilization Management 19 
Private Coverage of Drug Treatment 20 

Extent, Costs, and Trends of Coverage 20; 

Mandating Drug Treatment Coverage 21; Optimal Coverage Provisions 21 
Coda 22 

CHAPTER 1: INTRODUCTION 24 

The Logic of the Report 24 
Additional Policy Questions 26 

Treating Adolescents and Women with Children 26; 

The Criminal Justice System 27; The Socioeconomic Environment 27 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1 

CHAPTER 2: IDEAS GOVERNING DRUG POLICY 28 

The Character of Governing Ideas 28 
The Spectrum of Ideas About Drugs 29 

Libertarian Ideas 31; Medical and Criminal Ideas 32; 

The Classic Era of Narcotics Control 34 
The Rise of Modern Treatment 34 

Methadone Maintenance, 35; 

Therapeutic Communities, and Outpatient Nonmethadone Programs 35; 

Chemical Dependency Treatment 37; 

The Medical/Criminal Idea of Treatment and the Evolution of Governmental Roles 37 
Conclusion 39 



CHAPTER 3: THE NEED FOR TREATMENT 41 

The Individual Drug History: A Model and Overview 42 

Abstinence, Drug Types, and Normative Attitudes 44; 

Learning and Drug Experience 46; Environmental Variations 47; 

Age of Onset and Drug Sequencing 49; Diagnosing Dependence and Abuse 50; 

Recovery and Relapse 53 
Estimating the Extent of the Need for Treatment 54 

Household Survey Data 56; Criminal Justice Populations 59; 

The Homeless Population 65; Pregnant Women 65; Summary 66 
Quantifying the Consequences 66 
Conclusion 67 

Appendix 3A Estimating the Need for Treatment in the Household Population 69 
Appendix 3B Estimating the Need for Treatment Among Arrestees 71 
Appendix 3C Estimating the Costs of Drug Problems 72 

Drug-related Crime— Victim Losses 72; 

Crime Control Resources 73; Employee Productivity Losses 73; Health Costs 74 



CHAPTER 4: DEFINING THE GOALS OF TREATMENT 81 

Diverse Interests 82 

Reasons for Seeking Treatment 84 

Criminal Justice Agencies and Treatment 86 

Court Referral to Treatment 87; 

Prison and Parole Referral to Treatment 89; 

Preliminary Conclusions About "Mandatory Treatment" 91 
Employers and Treatment 92 

Employee Assistance Programs 92; Drug Screening Programs 93; 

How Employers View Drug Treatment 94 
Ambivalence and the Spectrum of Recovery 95 

Full, Partial, and Nonrecovery from Drug Problems 96; 

Setting Realistic Goals 97 
Conclusion 99 

iv NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



CHAPTER 5: THE EFFECTIVENESS OF TREATMENT 100 

Methadone Maintenance 102 

What Is Methadone Maintenance? 102; How Well Does Methadone Work? 107; 

Why Do the Results of Methadone Treatment Vary? 109; 

Costs and Benefits of Methadone Treatment 113; Conclusions 115 
Therapeutic Communities 116 

What Is a Therapeutic Community? 116; 

How Well Do Therapeutic Communities Work? 118; 

Why Do the Results of Therapeutic Communities Vary? 126; 

Costs and Benefits of Therapeutic Community Treatment 126; Conclusions 129 
Outpatient Nonmethadone Treatment 131 

What Is Outpatient Nonmethadone Treatment? 131; 

How Well Does Outpatient Nonmethadone Treatment Work? 131; 

Why Do the Results of Outpatient Nonmethadone Treatment Vary? 132; 

Benefits and Costs of Outpatient Nonmethadone Treatment 132 
Chemical Dependency Treatment 132 

What Is Chemical Dependency Treatment 132; 

How Well Does Chemical Dependency Treatment Work? 134; 

Why Do the Results of Chemical Dependency Treatment Vary? 135; 

Benefits and Costs of Chemical Dependency Treatment 135 
Detoxification 135 
Correctional Treatment Programs 137 

Stay'n Out and Cornerstone 137; 

The California Civil Addict Program 140; Boot Camps 142; 

Conclusions about Prison Treatment 144 
Summary and Conclusions About Treatment Effectiveness 145 

Methadone Maintenance 145; Therapeutic Communities 146; 

Outpatient Nonmethadone Programs 147; Chemical Dependency Programs 148; 

Detoxification 148; Correctional Treatment 148 
Recommendations for Research on Treatment Services and Methods 149 

Rebuilding the Research Base 149; Major Research Questions 150 



CHAPTER 6: TWO TIERS: PUBLIC AND PRIVATE SUPPLY 155 

The Two Tiers: An Overview 155 

Financing Differences 156; Client Differences 161; 

Capacity Differences 161 
The Growth of the National Treatment System 162 

Trends in Client Numbers and Provider Characteristics 162; 

Trends in the Funding Base 165; Sources of Treatment Dollars 166; 

Trends in Federal Funding 170 
Conclusion 170 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 

CHAPTER 7: PUBLIC COVERAGE 176 

The Principles of Public Intervention 177 

External Costs 177; Income Constraints 179; 

Positive Response to Treatment 181; Balancing Treatment Needs and Cost Concerns 182 
From Principles to Priorities 183 

Eliminate Waiting Lists 184; Improve Treatment 185; Reach More Young Mothers 186; 

Induce More Criminal Justice Clients to Accept Treatment 188 
Three Strategy Options 188 

The Core Strategy Option 189; Comprehensive and Intermediate Strategy Options 190 
Public Intervention in the 1990s 191; 

Federal and State Roles in the 1970s 191; The 1980s: Block Grants 193; 

The 1990s: Appropriate Shifts in Federal and State Roles 194; 

Transitional Steps Toward the Year 2000 196; Utilization Management 197 
The Special Case of Veterans' Coverage 199 
Conclusions 200 
Appendix 7 A Baseline and Strategy Option Calculations 201 

Baseline Comparison Values 201; Core Strategy Option 202; 

Comprehensive Strategy Option 204; Intermediate Strategy Option 206 
Appendix 7B Modeling Future Treatment Needs and Effects 208 
Appendix 7C Medicaid 209 

Coverage Policy Determination Under Medicaid 210; Eligibility 210; 

Coverage Provisions 211; The Current and Future Status of Medicaid Coverage 212 



CHAPTER 8: PRIVATE COVERAGE 214 

The Logic of Private Coverage 216 

The Extent of Private Insurance Coverage 217 

Employees of Private Companies 217; State and Local Government Employees 218; Federal 

Employees 219; Employers and Coverage Decisions 220 
Trends Affecting Private Coverage: Cost Containment of Health Benefits 221 
Private Insurance and State Mandates 225 

Access to Coverage 225; Adequacy of Coverage 226; 

Cost Containment 227; The Value of Additional Mandates 227 
Conclusions 228 

Extent, Costs, and Trends of Coverage 228; 

Mandating Drug Treatment Coverage 228; Optimal Coverage Provisions 229 

CODA 232 

REFERENCES 233 

BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS AND STAFF 247 

ACKNOWLEDGMENTS 251 

INDEX 253 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1 



FOREWORD 



This report was prepared in response to 
Congressional direction contained in Section 
6005, PL 99-570, the Anti Drug Abuse Act of 
1986. This Section of the law provided for the 
National Institute on Drug Abuse (NIDA) to 
fund the Institute of Medicine (IOM) to study 
the extent and adequacy of coverage by public 
programs, private insurance and other sources 
of payment for the treatment and rehabilitation 
of persons with drug abuse problems. The 
resulting IOM report, "Treating Drug 
Problems; A study of the evolution, 
effectiveness, and financing of public and 
private drug treatment systems," is 
comprehensive and thought provoking. It looks 
at a broad range of drug treatment and service 
delivery issues and provides an important 
compilation and analysis of what is known and 
not known of the nation's drug abuse services 
delivery systems. 

A Committee of outstanding drug abuse and 
health services researchers, practitioners and 
program planners was appointed by the IOM 
Division of Health Care Services to conduct this 
study. Their efforts included site visits to 
several treatment programs throughout the 
United States, analysis of available 
epidemiologic and services systems data on drug 
abuse, literature reviews, commissioned 
background papers, and interviews with experts 
in drug abuse treatment and services research, 
financing and delivery fields. 

Recommendations made by the Committee 
address both research and policy issues based 
upon their assessment of the current state of 
knowledge. They address issues involving data 
acquisition systems and the generation of 
reliable performance and outcome data; the role 



of standards for admission, care and program 
performance; the provision of services to special 
populations such as adolescents, pregnant 
women and mothers of young children; and the 
establishment of priorities for expanding public 
treatment programs and services. A number of 
these recommendations directly relate to public 
and private financing and reimbursement for 
drug treatment and related services research. 
Among these are the future role for publicly 
financed (Medicaid) drug abuse services, and 
reimbursement for free-standing drug treatment 
facilities. 

The recommendations in this report reflect the 
deliberations of the IOM committee. While 
NIDA does not necessarily agree or disagree 
with the conclusions and recommendations 
offered in this report, they will be useful and 
will be carefully considered as NIDA undertakes 
our research planning and management 
activities. This document will also contribute to 
the broader public dialogue regarding a number 
of drug abuse services issues. The solution to 
the complicated, difficult and costly problem of 
drug abuse and its vast consequences requires 
the concerted energies of us all. The wide 
distribution of this report is an effort to further 
discussion among the scientific, policy making, 
service delivery, and the public and private 
sectors involved in efforts to address these 
problems. 

Charles R. Schuster, Ph.D. 

Director 

National Institute on Drug Abuse 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



COMMITTEE FOR THE SUBSTANCE ABUSE COVERAGE STUDY 

LAWRENCE S. LEWIN,* Chair, Lewin/ICF Health Group, Washington, D.C. 

RAUL CAETANO, Alcohol Research Group, Institute of Epidemiology and Behavioral Medicine, Medical 
Research Institute of San Francisco at Pacific Presbyterian Medical Center, Berkeley, California 

DAVID T. COURTWRIGHT, Department of History, University of North Florida, Jacksonville, Florida 

DAVID A. DEITCH, Daytop Village, Inc., New York, New York, and Pacific Institute for Clinical Training, 
Education, and Evaluation, Berkeley, California 

DOUGLAS A. FRASER, Department of Labor Studies, Wayne State University, Detroit, Michigan 

JAMES G. HAUGHTON,* Martin Luther King/Charles R. Drew Medical Center, Los Angeles, California 

ROBERT L. HUBBARD, Center for Social Research and Policy Analysis, Research Triangle Institute, Research 
Triangle Park, North Carolina 

JAMES D. ISBISTER, Pharmavene, Inc., Gaithersburg, Maryland 

HERBERT D. KLEBER,** Substance Abuse Treatment Unit and Department of Psychiatry, Yale University School 
of Medicine, and APT Foundation, Inc. , New Haven, Connecticut 

JUDITH R. LAVE,* Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 

DAVID J. MACTAS, Marathon, Inc., Providence, Rhode Island 

DONALD J. McCONNELL, Connecticut Alcohol and Drug Commission, Hartford, Connecticut 

JOHN H. MOXLEY,* Health Care Division, Korn/Ferry International, Los Angeles, California 

PETER S. O'DONNELL, The KEREN Group, Princeton, New Jersey 

MARK V. PAULY,* Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, 
Pennsylvania 

HAROLD A. RICHMAN, Chapin Hall Center for Children and School of Social Service Administration, University 
of Chicago, Chicago, Illinois 

MAXINE L. STITZER, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of 
Medicine, and Francis Scott Key Medical Center, Baltimore, Maryland 

DEAN R. GERSTEIN, Study Director 

HENRICK J. HARWOOD,** Associate Study Director 

LINDA B. KEARNEY, Administrative Secretary 

ELAINE McGARRAUGH, Research Associate 

LEAH MAZADE, IOM Editor 

KARL D. YORDY, Director, Division of Health Care Services 



• « 



Member, Institute of Medicine. 

Herbert D. Kleber resigned August 17, 1989. and Henrlck J. Norwood resigned December 4, 1989. to accept positions in the 

Office of National Drug Control Policy, Executive Office of the President, Washington, D.C. 



vflf NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1 



PREFACE 



The committee members and staff appointed in 
1988 to conduct the Institute of Medicine's 
Substance Abuse Coverage Study were given a 
three-part task: 



investigate the extent of private and public 
funding of treatment for the chronic, relapsing 
disorders of drug abuse and dependence; 



evaluate the adequacy of funding patterns to 
meet the national need for rehabilitation of 
individuals with these disorders; and 



make recommendations to responsible parties, 
such as the U.S. Congress, which originally 
requested the study, regarding what they should 
do to meet the needs identified by the 
investigation. 



Based on its legislative title, the Substance Abuse 
Coverage Study seemed destined to focus on the 
design of health insurance benefits, which had 
entered the picture of drug treatment financing in 
a major way in the 1980s. But after carefully 
reviewing the charge, the character and 
organization of the treatment system, and the 
concerns that third-party payers on both the public 
and private sides persistently voiced about 
treatment programs and clients, the committee 
adopted a more comprehensive definition of its 
task. That definition is suggested by the title and 
descriptor chosen for this report: Treating Drug 
Problems; A study of the evolution, effectiveness, 
and financing of public and private drug treatment 
systems. The various chapters of the report 
discuss the history of ideas governing drug policy, 
the nature and extent of the need for treatment, the 
goals and effectiveness of treatment, the need for 
research on treatment methods and services, the 
costs and organization of the two-tiered national 



treatment system, the scope and organizing 
principles of public and private coverage, and 
recommendations tailored to each kind of 
coverage. Seven papers commissioned to inform 
and accompany the report are in a companion 
volume. 

Notwithstanding this broad range of issues, there 
are still some very important constraints and limits 
on what the committee has done and how this 
report should be understood. First, the report is 
about drug treatment and not about drug policy in 
general. Although the committee is careful to note 
where treatment fits within the context of 
prevention and law enforcement approaches to 
drug problems, it did not study these other 
approaches comprehensively. Consequently, its 
recommendations concerning additional resources 
for treatment do not derive from a systematic 
comparison of allocations for treatment versus 
allocations of comparable resources to law 
enforcement or prevention, but rather from a 
consideration of treatment needs alone. 
Comparison of the relative marginal benefits of 
these different approaches ultimately must be 
made, based on appropriate studies (which the 
report calls for), but it was not part of the 
committee's charge to perform this more 
encompassing task. 

A second limitation is that the committee's 
recommendations are confined to and reflect drug 
treatment in the United States. There is relevant 
scientific literature from other countries pertaining 
to treatment modalities in the United States, and 
the committee has explored these important 
sources. An adequate investigation of treatment 
systems in other countries, however, would require 
the same level of historical analysis, expert 
workshops, intensive site visiting in various 
localities, and other procedures that the committee 
employed in the United States. This type of 
careful international comparative study was beyond 
the committee's scope and resources. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



Ix 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



A third limitation is that the report does not delve 
into the treatment of alcohol problems. The 
committee recognizes that alcohol and drug 
problems overlap in a substantial proportion of the 
cases now being seen, a fact manifested by the 
range of problems most programs are willing to 
treat and the variety of services they provide. The 
limitation in scope here is largely due to a parallel 
study of alcohol treatment in the Institute of 
Medicine, chaired by Robert D. Sparks and 
directed by Frederick B. Glaser and Herman I. 
Diesenhaus; their committee's report, Broadening 
the Base of Treatment for Alcohol Problems 
(1990), is readily available from the National 
Academy Press. 

The alcohol study derived from the same 
legislation that initiated this study; however, the 
specific requests proceeded through separate 
federal channels and followed different timetables. 
Readers of both reports will easily see that 
problems associated with the two kinds of 
substances (legal alcohol and illegal drugs) and 
their partially divergent treatment systems justify 
separate investigations, even though the two have 
much in common. Both committees tried to 
maintain clear perspectives on each others' work 
while the studies were in progress. Mark V. 
Pauly served as a member of both committees, and 
there was other extensive liaison, including joint 
staff work. Now that both studies are completed, 
we are hopeful that a way will be found to draw 
the results even closer together, perhaps in a future 
report that focuses on the overlap of alcohol and 
drug problems. 

A fourth limitation is that the committee did not 
devote major energies to examining the 
relationship between drug treatment and AIDS (the 
acquired immune deficiency syndrome). Another 
committee of the National Academy of Sciences 
has recently completed two comprehensive studies 
of AIDS in its behavioral and social contexts, and 
their reports include a consideration of drug 
problems from the perspective of AIDS research 
and policy. We therefore refer the reader to 



AIDS: Sexual Behavior and Intravenous Drug Use 
(1989) and AIDS: The Second Decade (1990), 
which are both available from the National 
Academy Press. The latter report is particularly 
notable for its thorough analysis of women, 
adolescents, and AIDS. 

A final limitation on the scope of the committee's 
work was imposed by the scarcity of research data 
since the onset of the crack-cocaine era concerning 
treatment for drug dependence in women who are 
pregnant or mothers of young children. Of 
particular importance here is the question of how 
such treatment affects not only these women but 
also the quality of prenatal development, parental 
care, and environmental conditions in which their 
children are raised; and how, in turn, the 
children's health, behavior, and opportunities in 
life are affected when treatment intervenes. 
Another disheartening problem is the fragmentary 
knowledge base underpinning the treatment of drug 
abuse and dependence among adolescents. The 
absence of systematic research is perpetuated by 
excessive barriers to conducting treatment follow- 
up studies among individuals under 18 years of 
age. These obstacles arise because of 

inappropriate and unrealistic requirements at the 
federal level and in many states to obtain written 
parental consent for minors to participate 
(generally, through confidential interviews) in 
treatment services research. 

Although the committee was limited in these 
respects, we believe the report is fully responsive 
to its original charge, which expresses a legitimate 
and urgent national need. Perhaps in part because 
of the urgency of this need, the committee 
received willing assistance from many sources. 
Scores of individuals provided valuable 
information and trenchant ideas in extensive 
correspondence with the committee and in the 
formative workshops it organized during 1988 in 
Washington, D.C. and Irvine, California. The 
contributions of M. Douglas Anglin, who took part 
in both workshops and assisted the committee in 
other respects, deserve special mention. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1 



The committee is also indebted to programs and 
agencies that hosted committee site visits in New 
York, Miami/Dade County, Pittsburgh, St. Louis, 
the San Francisco Bay area, Los Angeles and 
Orange Counties, and Portland and Salem, 
Oregon. Closer to home, James M. Kaple and 
Albert M. Woodward, the study's project officers 
at the National Institute on Drug Abuse, were 
unfailingly helpful, constructive, and circumspect 
in facilitating the progress of the study. Charles 
R. Schuster, Salvatore di Menza, Edgar Adams, 
and other past and present staff of the National 
Institute on Drug Abuse were also instrumental in 
the acquisition of important data. 

The Research Triangle Institute, which performed 
the Treatment Outcome Prospective Study and the 
1988 National Household Survey on Drug Abuse, 
among other signal contributions to the field, 
provided invaluable assistance in developing this 
report, and its staff, particularly J. Valley Rachal 
and Lynn E. Guess, have earned the committee's 
thanks. Two former members of the Lewin/ICF 
staff, Nina E. Teicholz and Karen F. Monborne, 
directly assisted the chair, as did Lewin/ICF 
colleagues Jack Needleman and Robert J. Rubin. 

The authors of commissioned papers made major 
contributions to the committee's thinking and 
responded graciously to its many requests for 
more, less, different, or clarifying information. 
The committee does not necessarily concur with 
every conclusion drawn by these authors; 
nevertheless, we learned a great deal from them 
and are pleased to publish their papers in a second 
volume of the report. 



Speaking for ourselves and for the members of the 
committee, we cannot praise too highly the quality 
and dedication of the Institute of Medicine staff. 
Linda B. Kearney, administrative secretary, and 
Elaine McGarraugh, research associate, performed 
coolly and indefatigably in disposing of an 
unending succession of logistical and technical 
requirements. The ingenuity, eye for detail, and 
good judgment of these veterans kept the study on 
track in the face of numerous complications. 
Technical editor Leah Mazade carefully graced and 
polished every line of text in preparing the report 
for publication. Henrick J. Harwood, associate 
study director and co-editor of the report, left late 
in the study to serve in the White House Office of 
National Drug Control Policy— but not before 
organizing and leading several intensely valuable 
site visits, completing state-of-the-art literature 
reviews and data analyses, and generally earning 
the very highest regard of the committee. 

Finally, we are fortunate to have a committee 
whose members are thoroughly distinguished in 
their professional achievements, demanding in 
their intellectual standards, congenial and 
unassuming in person, and thoughtful, persistent, 
and generous in their abiding commitment to the 
public good. On behalf of this splendid group, we 
are pleased to submit the report of the Substance 
Abuse Coverage Study. 



Lawrence S. Lewin, Chair 
Dean R. Gerstein, Study Director 



The committee also benefited from a perceptive 
and unusually extensive set of review comments 
solicited by the Institute of Medicine. These 
reviews stimulated many specific improvements in 
the draft report, and their contributors represent an 
admirable tradition of unsung, voluntary 
professional service to the public interest. We are 
grateful to be among its beneficiaries. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



QUESTIONS THE REPORT ANSWERS AND 

THOSE IT LEAVES UNRESOLVED 

(CHAPTER 1) 

The Anti-Drug Abuse Act of 1986 called for the 
Institute of Medicine (IOM) to conduct a study of 
the extent and adequacy of coverage by public 
programs, private insurance, and other sources of 
payment for the treatment and rehabilitation of 
drug abusers. The act also requested IOM to 
recommend the means by which the needs 
identified in the study could be addressed. In 
responding to this charge, the committee 
established to conduct the study has covered the 
following major questions in its report: 

■ The role of treatment— What is the role of 
treatment in the ideas that govern and shape 
drug policy? (Chapter 2) 

■ The need for treatment— In light of the 
patterns of drug consumption and consequent 
problems, what is the estimated extent of the 
need for drug treatment? (Chapter 3) 

■ The goals of treatment— What should drug 
treatment seek to accomplish in the context 
of treatment seekers' motives and medical- 
criminal drug policies? (Chapter 4) 

■ The effects of treatment— What are the 
available modalities of drug treatment? What 
are their expected and actual clinical 
accomplishments? Why do the results of 
treatment programs vary? What are their 
respective benefits and costs? (Chapter 5) 

■ The organization of treatment— How, in 
general, is the supply of treatment organized 
and financed? (Chapter 6) 

■ Public coverage— What is the rationale, the 
priorities, and the optimal level of public 
coverage of drug treatment? How can public 



coverage be best arranged and managed? 
(Chapter 7) 

■ Private coverage—What are the 
responsibilities of private coverage for drug 
treatment in terms of eligibility, benefit and 
service design, costs, and care management? 
(Chapter 8) 

In answering these questions, and more detailed 
ones within each chapter, the committee relies on 
the preponderance of rigorous evidence (where 
enough evidence is available to be weighed) and 
judiciously uses expert judgment, including 
specification of the new knowledge needed to 
strengthen this judgment, where logic and 
experience point strongly but rigorous evidence is 
scant. In view of the severity and complexity of 
the drug problem and the public's determination to 
respond, the committee tries to recommend policy 
decisions regarding drug treatment that are most 
consistent with the current state of knowledge. 

There are three important questions relevant to the 
drug problem that the committee returned to more 
than once but could not answer in this study. In 
one case, neither evidence nor experience were 
sufficient to counsel a specific judgment; in the 
other two cases, the questions— and the expertise 
and evidence needed to answer them— were outside 
the committee's charge and resources. The most 
urgent unanswered questions in this regard are the 
following: 

■ With sufficient resources and related 
services, would different drug treatment 
modalities than the ones now available be 
more effective for adolescents and mothers 
of younger children? 

■ How efficient and effective is the current 
distribution of criminal justice responses to 
the drug problem? 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



How can society intervene more effectively 
in socioeconomic environments to prevent 
drug initiation and discourage rather than 
facilitate relapse? 



IDEAS GOVERNING DRUG TREATMENT 
POLICY (CHAPTER 2) 

The national response to drugs has always been 
governed by simple, powerful ideas about the 
nature of the drug problem and how to control it 
(see Figure 2-1). ' 



■ From Revolutionary times to the 
Reconstruction era, the drug problem was a 
minor concern, left at first to the realm of 
private behavior, and later managed in a 
loosely enforced regulatory framework; this 
approach derived from libertarian ideas. 

■ A medical conception of opiate and other 
addictions was formulated in the late 1800s, 
explaining clinical observations among drug- 
consuming older women and other groups. 
Various treatment approaches were devised, 
including detoxification and, where total 
abstinence was deemed unachievable, 
medically supervised maintenance. 

■ From 1910 to the 1920s, medical approaches 
were almost wholly swept aside by the rise of 
a criminal conception of the problem 
focusing on underworld characters who used 
heroin and other drugs. That conception held 
sway, with little effective challenge, for 40 
years. 

In the 1960s and 1970s, medical ideas reappeared 
in more sophisticated forms, taking much more 
explicit account of the various criminal contexts of 
drug use. During 1965-1975, a national medical- 
criminal treatment policy was made viable chiefly 
by the emergence of promising new treatment 

'The tables and figures referred to in this summary appear in 
the chapters of the report. 



modalities: methadone maintenance and 

therapeutic communities for heroin and outpatient 
nonmethadone programs oriented toward nonopiate 
drugs. In the same period the federal government 
sponsored the build-up of a substantial public tier 
of community -based drug treatment programs. 
This system of programs was the leading edge of 
national drug policy, complementing criminal 
justice efforts in responding to drug-related crime. 

Other factors that contributed to the reemergence 
of medical ideas were a shift in attitudes during the 
"Great Society" period that brought a greater 
assumption of collective responsibility for the 
casualties of socioeconomic forces. This shift was 
followed by the Nixon administration's energetic 
search for responses to large-scale unrest, 
particularly the social problems of increasing crime 
and heroin use. 

From 1975 to 1986, federal dollar support for 
drug treatment eroded, although states moved to 
replace this support to some degree. The growth 
of the community-based public tier of treatment 
stopped while the criminal justice system as a 
whole entered a period of unprecedented sustained 
increase. The momentum of medical ideas shifted 
to a rapidly expanding private tier. In the 1980s, 
chemical dependency programs, largely comprising 
hospital-based alcohol treatment providers, began 
treating growing numbers of heavy alcohol and 
drug consumers (mostly of cocaine and marijuana) 
who could afford to pay with private insurance 
coverage or personal assets. 

The public tier of drug treatment has been the 
neglected front in the drug wars of the 1980s. In 
formulating the federal anti-drug abuse legislation 
of 1986 and 1988, the great bulk of the debate and 
the new sums actually spent were directed toward 
enforcement against traffickers and prevention 
among nonusers. Outside of concern with 
isolating the growing acquired immune deficiency 
syndrome (AIDS) epidemic, public treatment was 
all but ignored. 

With the rise in alarm about crack-affected 
children and neighborhoods, however, the 



NIDA DRUG ABUSE SERVICES RESEARCH SER/ES, No. 2 



SUMMARY 



pendulum of public policy is once again moving. 
Modalities of treatment attuned to medical-criminal 
ideas again seem increasingly attractive. It is 
becoming widely appreciated that the drug problem 
does not lend itself to simple characterization or 
solution, that a combination of ideas and policies 
is the most fruitful way to respond to it, and that 
treatment programs can and should reflect this 
principle of combination. 



DRUG PROBLEMS AND THE 

NEED FOR DRUG TREATMENT 

(CHAPTER 3) 

Patterns of Drug Consumption 

The nation's drug problem is a complicated 
evolving composite of millions of individual 
patterns of drug-consuming behavior and 
consequences that may differ according to time and 
place and that change as the marketing, 
technology, and reputations of drugs evolve. 
Crack-cocaine, heroin, marijuana, amphetamines, 
and all other illicit drugs are consumed in patterns 
that range from experimental use to dependence. 
To determine the extent of need for treatment in 
the population, drug consumers must be 
categorized based on the frequency and amount of 
their drug consumption and the severity of 
associated problems and consequences. 

A conceptual paradigm of individual drug 
consumption, consequences, and societal responses 
is presented in Figure 3-1. Although individual 
patterns are not always so orderly, patterns or 
types of drug taking in this simplified scheme 
occur in progressive stages of use, abuse, and 
dependence, each more hazardous and intrusive 
than the one before. Each stage entails the risk of 
further progression, but progression is not 
inevitable. A minority of experimental users reach 
the stage of abuse, fewer yet the stage of 
dependence. 

The bulk of initial, experimental drug use occurs 
during the teenage years. Very few children aged 



10 or younger have begun to use drugs. Nearly as 
few people begin using drugs— or even any 
particular type of drug, unless it was never 
previously available— after reaching 25 years of 
age. 

For many years, the introduction to drugs in the 
great majority of cases that go on to further stages 
has proceeded in a general cumulative sequence: 
alcohol and tobacco, to marijuana, to other 
inhalable or orally ingestible substances, to 
hypodermic injection of opiates or powerful 
stimulants (cocaine, amphetamines). This 

sequence is almost always initiated between the 
ages of 12 and 15, and the injection phase, when 
reached, generally begins between the ages of 17 
and 20. The sequencing phenomenon is thought to 
reflect drug availability and the degree of 
opprobrium attached to respective types of drugs. 
However, as the marketing of cocaine continues to 
expand and that of marijuana diminishes, the 
sequence of introduction to these drugs may 
become less uniform. 

The mixture of drug effects that consumers seek or 
are satisfied with tends to change subtly over time, 
moving typically from just "getting high" or being 
sociable in the early stage of use to the 
achievement of temporary relief from the persistent 
desire or learned need for a drug (which persists 
even after short-term withdrawal is completed) in 
the stage of dependence. Drug-seeking behavior 
is highly volitional during initiation and 
continuation of use, although profoundly 
influenced by the environment. But the initial 
voluntary component of drug-seeking behavior is 
typically compromised by the psychological, 
physiological, and social aspects of the dependence 
process, which dramatically increases the 
probability that treatment will be needed to 
extinguish drug-seeking behavior. 

Dependence 

Dependence (not only on illicit substances but also 
on such licit agents as alcohol and tobacco) is the 
most extreme pattern of drug consumption. It is 
the persistent seeking and consumption of one or 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



more types of drugs in excessive amounts, despite 
such high costs as the accumulation of harm to 
health and functioning, viewed broadly by social 
standards and judged specifically according to 
clinical diagnostic criteria. The most severely 
drug-impaired individuals are dependent on one 
drug and make heavy use of one or more others 
(including alcohol), perhaps to the point of 
multiple dependencies. Many such individuals also 
have serious mental illnesses and medical 
complications. 

There is a range of individual vulnerability to drug 
dependence when environmental conditions are 
held constant. But social environments are not 
constant, and variation in environmental conditions 
correlates strongly with ecological variation in 
drug dependence rates. 



Recovery and Relapse 

Drug dependence is characteristically a chronic, 
relapsing disorder. Drug abuse often assumes this 
character as well, but not as often. Dependent 
drug-seeking behavior and the strong desire or 
craving for drugs that is its subjective aspect are 
difficult to lose completely, or extinguish, once 
they have been established. It is easier to 
complete detoxification (the short-term transition 
from being acutely dependent to being free of 
dependence symptoms) than it is to sustain that 
asymptomatic state beyond the short term—that is, 
to avoid relapse. Nevertheless, individuals can 
successfully put a complete stop to an established 
pattern of chronic dependent behavior. Not only 
can they safely stop using drugs in the short term, 
with or without formal assistance, but they can 
also avoid the recurrence of drug seeking that ends 
in relapse. This extinguishing of individual 
drug-seeking behavior is the most fundamental 
element in the recovery process. 

Studies of the life history of dependent individuals 
indicate that there is usually a complicated path to 
recovery. Individuals with severe problems 
(including deficits in their social environment) that 
precede their drug dependence or abuse—for 



example, family disintegration, lack of legitimate 
job skills or opportunities, illiteracy, or psychiatric 
disorders— will probably continue to have these 
problems unless specific services are available to 
deal with them. These individuals are also at 
intrinsically high risk of relapse. 

Many individuals are too damaged by the 
consequences of drug dependence or other factors, 
too bereft of alternative behavioral skills and 
supports, to complete (sometimes even to begin) 
the recovery process without lengthy or continuing 
help in coping with psychological, social, 
economic, or pharmacological problems. For 
these individuals, recovery is not only a matter of 
extinguishing drug-seeking behavior but also of 
addressing directly a range of functional 
impairments that usually preceded drug seeking 
and were worsened by it. Recovering functionality 
in society to whatever degree is possible is a more 
comprehensive definition of recovery. 

Treatment of drug problems, therefore, often 
addresses itself not only to drug consumption as 
such but also to the chronic personal impairments 
and social and economic deficits that often 
characterize those who enter treatment. 
Individuals without accompanying problems, who 
have long-term assets such as a stable job and 
supportive family, are not likely to need specific 
adjunctive services and have been found to be 
intrinsically less likely to relapse. 

It is characteristic of recovery processes from any 
type of drug dependence that, although many 
people do recover, recovery is seldom achieved, or 
even begun, before the individual recognizes that 
he or she has suffered and caused significant 
personal and social harm— an understanding that 
often requires overcoming a strong tendency to 
denial. The more severe and prolonged the 
periods of dependence or severe abuse, the greater 
the need for help in extinguishing drug-consuming 
behavior. 

Autonomous cessation, or self- recovery, although 
not uncommon, is not universal. Many, probably 
the majority, of those who are dependent or severe 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



abusers relapse after their first (and later) attempts 
at self- recovery. Most people who enter drug 
treatment have tried self-recovery previously but 
did not succeed. Most people who recover after 
treatment do so after more than one treatment 
episode. 



Determining the Need for Treatment 



Drug treatment is (or in most cases should be) an 
intensive, personalized intervention. Treatment is 
not an appropriate or efficient response to the most 
common patterns of drug consumption, namely, 
experimental and occasional use, and may not be 
needed in cases of abuse in which impairment is 
slight or the pattern of abuse is new. Other 
interventions, such as brief preventive counseling, 
educational services, and disciplinary sanctions, 
may be legitimate, useful, or effective in 
promoting cessation and abstinence in these 
instances. 

Formal diagnostic criteria for determining the 
appropriateness of treatment have evolved over the 
years and now encompass a constellation of drug- 
related problems rather than focusing exclusively 
on classical signs such as tolerance and withdrawal 
symptoms. Practice in diagnosis is highly 
variable; nevertheless, the majority of individuals 
entering drug treatment programs are dependent or 
severe abusers by any reasonably discriminating 
criteria. 

In the committee's judgment, drug treatment is 
justified and appropriate for an individual if there 
are clinically significant signs of dependence or 
chronic abuse. Assessment of individual problem 
severity and the degree of help needed for 
recovery is thus exceedingly important. These 
factors are usually but not always taken into 
account in matching individual treatment seekers 
with appropriate modalities and in "fine-tuning" 
treatment by choosing among specific therapeutic 
components. 



Estimating the Aggregate Need for Treatment 

An estimated 5.5 million Americans clearly or 
probably need treatment at this time, which is 
somewhat more than 2 percent of the total 
population over 12 years of age. About one-fifth 
of the estimated population needing treatment— and 
two-fifths of those who clearly need it— are under 
the supervision of the criminal justice system as 
parolees, probationers, or inmates (see Table 3-4). 

In the household population not under criminal 
justice supervision, those clearly or probably 
needing drug treatment are two-thirds male and 
heavily concentrated among adults aged 18 to 34. 
Youths under the age of 18 make up about 9 
percent (about 400,000 persons) of the total 
household group needing treatment, and adults 
over 34 account for about 16 percent (roughly, 
725,000 persons). Most of the household adults— 
75 percent— hold some type of job at least part of 
the time, 10 percent are unemployed (twice the 
national average), and 15 percent are in school, 
retired, disabled, or carrying household 
responsibilities. 

Current survey and surveillance data indicate that, 
although lighter drug consumption— experimental 
and occasional use— is becoming less prevalent, the 
problem of severe drug abuse and dependence is 
growing larger, more difficult, and more costly. 
The difficulties are due both to the expanded menu 
of drugs that are now widely consumed— most 
prominently, marijuana and cocaine, barbiturates 
and other depressants, amphetamines and PCP in 
some parts of the country, and heroin— and to the 
complications induced by AIDS, chronic 
unemployment, and extended family disintegration 
in the inner cities. Because of the complex, 
protean, time-extended character of the drug 
problem, aggregate treatment needs are not 
necessarily closely linked to the current overall 
societal prevalence of drug involvement. Total 
social costs are especially difficult to estimate, 
being subject to many uncertainties of 
measurement. The costs of drug problems in the 
form of treatment for AIDS, prevention programs, 
and drug treatment programs are not insubstantial, 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



but they are clearly much smaller than the costs 
incurred as a result of drug-related crime. 



THE GOALS OF DRUG TREATMENT 
(CHAPTER 4) 

To know whether treatment is appropriate and 
whether the money it costs is well spent, the goals 
of treatment need to be made explicit. Lifetime 
abstinence from all illicit drug consumption is the 
central goal of drug treatment. However, in light 
of the chronic, complex nature of drug problems, 
the more pragmatic day-to-day objective is to 
reduce illicit drug consumption by as large a 
fraction as possible relative to the consumption one 
might expect in the absence of treatment. 
Reduction of illicit drug consumption produces 
socially and personally valuable results and may 
serve as a critical intermediate step to lifetime 
abstinence. A useful shorthand for the pragmatic 
goal of drug treatment is that it tries to initiate, 
accelerate, and help sustain the recovery process. 

The goals of the treatment delivery system are not 
confined to reducing the drug consumption of 
specific individuals. These goals, assigned overtly 
or implicitly by public policy or private payers, 
are multiple and may include the following: 

■ reduce the overall demand for illicit drugs; 

■ reduce street crime; 

■ change users' personal values; 

■ develop educational or vocational capabilities; 

■ restore or increase employment or 
productivity; 

■ improve the user's overall health, 
psychological functioning, and family life; 
and 

■ reduce fetal exposure to drug dependence. 

Success in achieving one set of these goals may be 
related to but is not equal to success in achieving 
the others. Generally, the more severely the user 
is impaired with respect to these various goals 
when he or she enters treatment, the more services 
will be needed for drug treatment to be effective. 



Motivations for Treatment 

The nature and success of drug treatment is 
complicated by the typical reluctance of dependent 
or abusing individuals to seek treatment or stay in 
it. The main reason for this reluctance is that drug 
consumers like drugs; drugs "work" for them and 
provide the effects they seek, which vary from 
pleasure to relief. Drug dependence or abuse, in 
and of itself, is often not what sends people to 
treatment, at least, not initially. Individuals often 
enter treatment as a strategy of partial rather than 
full recovery— that is, to help manage serious 
problems with the law, their family, their mental 
or physical health, other drug consumers or 
dealers, a threat involving criminal justice 
supervision, or an abrupt loss of customary 
income. In other words, they may enter treatment 
to establish better control over their drug behavior 
or its consequences but not necessarily to 
extinguish the behavior entirely. Another factor 
that contributes to some individuals' reluctance to 
enter or stay in treatment is that drug treatment is 
often demanding, imposing schedules and controls 
and requiring extensive work on the part of the 
client to overcome social deficits and heal 
psychological impairments. 

Overall, because of the inherent disinclination 
toward drug treatment, some form of perceived 
threat or pressure is nearly always present as a 
triggering element when treatment is sought. The 
pressure can derive from an internal or an external 
problem, which is usually but not necessarily a 
direct consequence of drugs. The most common 
internal pressure is the cumulative and 
demoralizing realization that the increasing trouble 
that comes with sustained drug abuse or 
dependence leads to a dead end. 

Clients formulate exterior motives for entering 
treatment as "to get [someone] off my case." 
External pushes are usually allied to some degree 
of positive pull or motivation to change. The 
positive motives are often not strong enough in 
themselves to initiate or sustain recovery, but 
reinforcement through external pushes into 
treatment and therapeutic pressure within treatment 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



can be effective in doing so. The specific mixture 
and source of motives vary with the circumstances. 
For someone with a high-paying, prestigious job, 
the direct threat of losing that livelihood and 
position can carry a great deal of weight. For 
someone who is unemployed and unskilled, no 
threat short of a long prison sentence may carry a 
comparable degree of weight or pressure. The 
civil liberties implications of this inequity are 
troubling, but such is currently the state of affairs. 



Treatment and Criminal Justice 

The treatment system and crime control systems in 
this country share important goals—especially, the 
attainment of less criminal and drug-involved lives 
by their clientele. On a given day, out of 1 
million persons in confinement, there are probably 
40,000 individuals in jail or prison custody who 
are also in drug treatment programs. More 
broadly, many courts and correctional systems use 
commitment or referral to community-based 
treatment programs, usually ones involving close 
supervision, as alternatives or adjuncts to 
probation or parole status. Half or more of the 
admissions to typical community-based residential 
and outpatient drug treatment programs (except 
perhaps for methadone) are on probation or parole 
when they enter treatment. These statistics are a 
direct manifestation of the criminal-medical policy 
idea regarding the drug problem. 



Criminal justice referral to treatment occurs for 
several reasons, including relief of court and 
prison overcrowding. Treatment takes 

responsibility for a case somewhat out of the 
criminal justice system, reduces the high cost of 
continuing incarceration, and assures a degree of 
supervision beyond what probation or parole 
offices may be able to afford. When referral 
occurs to relieve overcrowding, however, the 
stipulation "go to treatment and comply with the 
program or risk being returned to custody" loses 
its credibility. The more overcrowded and 
strained the criminal justice system, the less 
pressure it can muster to help push any particular 
individual into seeking and complying with 
treatment. 

There is frequent favorable reference today to 
"mandatory," "compulsory," or "required" 
treatment. Contrary to earlier fears among 
clinicians, criminal justice pressure does not 
necessarily vitiate treatment effectiveness and 
probably improves retention. Yet the most 
important reason to consider these or related 
schemes to compel more of the criminal justice 
population to seek treatment is not that coercion 
may improve the results of treatment but that 
treatment may improve the rather dismal record of 
plain coercion— particularly imprisonment— in 
reducing the level of intensively criminal behavior 
that ensues when the coercive grip is relaxed. 



The criminal justice system is already the largest 
single source of external pressure on individuals 
leading them to enter drug treatment. In most 
cases, the court (or another criminal justice 
agency) has simply ordered the individual to stay 
free of drugs and crime or else be remanded to 
custody. In this instance the individual chooses to 
seek treatment under the assumption that avoiding 
drug use (or at least avoiding abuse or 
dependence, which are far more troublesome and 
difficult to conceal) will be facilitated by 
treatment. In more direct cases the court or other 
agency offers the client a choice, generally 
between a term in prison and a period of probation 
or parole with treatment. 



THE EFFECTIVENESS OF TREATMENT 
(CHAPTER 5) 

In the context of a medical-criminal policy, the 
practical objective of treatment at present is 
primarily to reduce illicit drug consumption and 
other criminal activity, secondarily to increase 
success in conventional activities such as 
employment and child rearing, and to improve 
health status, including, most recently, reducing 
AIDS risk behavior among clients. The standard 
for success is whether behavior during and after 
treatment is appreciably better than what would 
probably occur in the absence of treatment. 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



Does drug treatment achieve these goals? It 
varies; for a more discriminating answer, it is 
necessary to pose a more sophisticated set of 
questions. 

■ What are the basic concepts or modalities of 
treatment? That is, what are the underlying 
designs or theories of treatment, what 
specific types of drug problems or population 
groups are being addressed by each design, 
and what are the best results that have been 
obtained under ideal conditions? 

■ How well does each modality work in 
practice? If a modality works less well than 
might be expected, what are the reasons for 
this variance? For example, is the 
implementation or replication of the modality 
flawed or incomplete? Are the wrong kinds 
of clients being treated? Are there 
unexpected side effects? Does the 
environment neutralize the effectiveness of 
the treatment? 

■ Do the benefits of treatment justify the costs? 
In other words, is treatment a good 
investment? 

■ In addition to the above questions about 
treatment as it exists: How might further 
research help to improve treatment? 

All of these questions must be asked, but they 
cannot all be answered at present. There are four 
major modalities of drug treatment for which 
answers of varying confidence can be supplied: 
methadone maintenance clinics, residential 
therapeutic communities, outpatient nonmethadone 
treatment, and chemical dependency units. The 
most extensive and scientifically best-developed 
evidence concerns methadone maintenance. A 
lower although still suggestive level of evidence is 
available for therapeutic communities and 
outpatient nonmethadone programs. An even 
lower level of evidence is available for drug 
treatment in the chemical dependency modality. 
Except for a description of the model, there are 
virtually no data to answer any of the critical 



questions for the quasi-treatment modality of 
mutual self-help groups, such as Narcotics 
Anonymous. 

The most extensive usable results of research on 
the effectiveness of drug treatment are from 
several planned experiments and natural or quasi- 
experiments and from prospective longitudinal 
studies involving thousands of clients. There have 
been two large-scale, multisite, federally sponsored 
studies: the Drug Abuse Reporting Program 
(DARP), a 12-year follow-up of a 1969-1971 
national admission sample cohort, and the 
Treatment Outcome Prospective Study (TOPS), 
which involved a 10,000-person representative 
sample of 1979-1981 admissions to 41 drug 
treatment programs in 10 cities, followed for up to 
5 years. DATOS (the Drug Abuse Treatment 
Outcome Study), a third large-scale national 
prospective study, is scheduled to begin in 1990; 
important related studies are under way. 

Drug users and treatment programs do a 
substantial amount of selection according to client 
characteristics and modality. The modalities were 
designed for different types and severities of 
problems, and prospective clients often have very 
set ideas about what type of treatment they want. 
As a result, the profiles of clients admitted to the 
major modalities are quite different, and one 
cannot compare the performance or results of each 
modality with the others as if they were all simply 
interchangeable. 



Methadone Maintenance 

Methadone maintenance is a treatment for 
extended dependence on opiate drugs (usually 
heroin). A sufficient daily oral dose of methadone 
hydrochloride, which is a relatively long-acting 
narcotic analgesic, yields a very stable metabolic 
level of the drug. Once a newly admitted client 
has reached a stable, comfortable, noneuphoric 
state, without the psychophysiological cues that 
precipitate opiate craving, he or she is amenable to 
counseling, environmental changes, and other 
social services that can help shift his or her 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



orientation and lifestyle away from drug seeking 
and related crime toward more socially acceptable 
behaviors. 

Methadone programs are nearly always 
ambulatory, with daily visits to swallow the 
methadone dose under observation in the clinic, 
except for traditional Sunday take-home doses. 
After several months in the program with a 
"clean" drug testing record and good compliance 
with other program requirements, one or more 
daily doses may be regularly taken home between 
less-than-daily visits; however, this convenience is 
a revocable privilege. Some methadone clients 
voluntarily reduce their doses to abstinence and 
conclude treatment after some time, whereas others 
remain on methadone indefinitely, particularly if 
earlier attempts to leave methadone have ended in 
relapse. 

Methadone maintenance has been the most 
rigorously studied modality and has yielded the 
most positive results for those who seek it. Yet it 
is also the most controversial treatment, largely 
based on the judgmental grounds that methadone 
clients have "merely" switched their dependence to 
a legal narcotic and that many clients continue to 
use heroin and other drugs intermittently and to 
commit crimes, including the sale of their take- 
home methadone. 

In the committee's judgment, these controversies 
and reservations are neither trivial nor in 
themselves compelling. Methadone is an opiate 
drug, but consumption of a stable, clinically 
appropriate oral methadone dose is not 
behaviorally or subjectively intoxicating and does 
not impair functioning in clinically detectable 
ways. Toxic side effects during long-term 
treatment are extremely rare, and the general 
health of methadone clients improves markedly 
compared with their status when using heroin. 
Prior to admission, the great majority of 
methadone clients had been consuming high levels 
of illicit drugs and committing other crimes 
(including drug selling) on a daily basis. Some 
programs have very good and others very poor 



client compliance with rules against illicit drug use 
and criminal activity. 

The issues are to what extent undesirable behaviors 
are reduced and positive behaviors increased as a 
result of methadone maintenance, in comparison to 
no treatment or to alternative measures, and 
whether poorly performing programs can be 
improved. Regarding behavior and treatment, the 
extensive evaluation literature on methadone 
maintenance yields firm conclusions as follows: 



■ There is strong evidence from clinical trials 
and similar study designs that opiate- 
dependent individuals have better outcomes 
on average in terms of illicit drug 
consumption and other criminal behavior 
when maintained on methadone than when 
not treated at all, when simply detoxified and 
released, or when methadone is tapered 
down and terminated as a result of client 
request, program expulsion, or program 
closure. 

■ Methadone clinics have significantly higher 
retention rates for opiate-dependent 
populations than do other treatment 
modalities for similar clients. 

■ Although methadone dosages need to be 
clinically monitored and individually 
optimized, clients have better outcomes when 
stabilized on higher rather than lower doses 
within the typical ranges currently prescribed 
(30 to 100 milligrams per day). 

■ Following discharge from methadone 
treatment, clients who stayed in treatment 
longer have better outcomes than clients with 
shorter treatment courses. 

It is important to note that most of these results 
date from the 1970s to the early 1980s. Since 
then, the expanding cocaine market has created 
additional strains on many methadone programs. 
Methadone has no direct pharmacological bearing 
on the metabolism of cocaine (as it does on that of 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



opiates); in addition, most methadone programs' 
counseling and other clinical resources have been 
substantially eroded or limited as a result of fiscal 
constraints. Moreover, the high seroprevalence of 
human immunodeficiency virus (HIV), which is 
generally acquired long before program admission, 
and the prevalence of AIDS symptoms and deaths 
create a heavy medical and psychological burden 
on methadone programs (and others, such as 
therapeutic communities, which serve the most 
severely impaired drug-using groups) in cities in 
which the AIDS epidemic is far advanced. 



Therapeutic Communities 

Therapeutic communities (TCs) are residential 
programs with expected stays generally of 9 to 12 
months, phasing into independent residence with 
continuing contact for a variable period. TC 
programs are highly structured blends of 
resocialization, milieu therapy, behavioral 
modification practices, progression through a 
hierarchy of occupational training and 
responsibility within the TC, community reentry, 
and a variety of social services. TCs originally 
used very rigid program models and relied 
extensively on recovering "graduates" as program 
staff. They have become more flexible in program 
design and more multidisciplinary in staffing over 
time while retaining their core features, including 
an absolute prohibition on any drug use or violent 
behavior by clients during treatment. 

Therapeutic community clients are more diverse in 
their drug use patterns than methadone clients 
because the modality is not specific to any 
particular class of drugs. From the 1960s to the 
early 1980s, a majority of TC clients were 
primarily dependent on heroin. In the later 1980s, 
cocaine dependence began to predominate in many 
programs. Therapeutic communities are designed 
for individuals with major impairments and social 
deficits, including histories of serious criminal 
behavior. 



The primary conclusions 
communities are as follows: 



on therapeutic 



TC clients demonstrate better behavior (drug 
use, criminal activity, social productivity) 
during treatment and after discharge than 
before admission. 

The minimum retention necessary to yield 
posttreatment improvement in long-term 
users seems to be at least 3 months, with 
further improvement continuing to be evident 
for full-time treatment of up to 12 to 18 
months. 

TC clients demonstrate better outcomes at 
follow-up than individuals who contacted but 
did not enter the same treatment programs. 

Graduates of TCs have better outcomes at 
follow-up than dropouts from the same 
programs. 

The length of stay in a TC is the strongest 
predictor of outcomes at follow-up. 

Attrition from TCs is typically high— above 
the rates for methadone maintenance but 
below the rates for outpatient nonmethadone 
treatment. 



Outpatient Nonmethadone Programs 

Outpatient nonmethadone programs display a great 
deal of heterogeneity in their treatment processes, 
philosophies, and staffing. The clients are 
generally not opiate dependent but otherwise vary 
across all types of drugs. They also tend to have 
less serious criminal histories than methadone or 
TC clients and to include more nondependent 
individuals. Outpatient nonmethadone programs 
generally provide one or two visits per week for 
individual or group psychotherapy /counseling, with 
an expected course averaging about six months. 

Despite the heterogeneity of programs and their 
clients, the limited number of outcome evaluations 
of outpatient nonmethadone programs have 
generated conclusions qualitatively similar to those 
from studies of TCs: 



w 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



Outpatient nonmethadone clients during and 
following treatment show better performance 
than before treatment. 



are either more or less effective for drug problems 
than CD programs not sited in hospitals. 



Those clients actually admitted to programs 
have better outcomes than clients contacting 
but not entering programs (and clients only 
undergoing detoxification) . 

Graduates have better outcomes than 
dropouts. 

Outcome at follow-up is positively related to 
length of stay in treatment. 

Retention in nonmethadone outpatient 
programs tends to be poorer than for 
methadone maintenance or therapeutic 
communities. 



Chemical Dependency Programs 

Chemical dependency (CD) programs generally are 
residential or inpatient, with a three- to six-week 
duration, followed by up to two years of attending 
self-help groups or a weekly outpatient therapy 
group. CD programs are based on an Alcoholics 
Anonymous (12-step) model of personal change 
and the belief that vulnerability to dependence is a 
permanent but controllable disability. Its goals are 
those of total abstinence and lifestyle alteration. 

Chemical dependency programs largely treat 
primary alcoholism, and they have not been 
carefully evaluated for treatment of drug problems. 
A few follow-up studies of individuals who have 
completed CD treatment indicate that clients whose 
primary problem is drugs have poorer outcomes 
than clients whose primary problem involves 
alcohol. 

CD programs are often located in hospitals. In the 
committee's judgment, none of the model 
therapeutic core elements of this modality require 
the presence of acute care hospital services. There 
is no evidence that hospital-based CD programs 



Detoxification 

Detoxification is therapeutically supervised 
withdrawal to abstinence over a short term, that is, 
up to 21 days but usually 5 to 7 days, often using 
pharmacological agents to reduce client discomfort 
or the likelihood of medical complications. 
Detoxification is seldom effective in itself as a 
modality for bringing about recovery from 
dependence, although it can be used as a gateway 
to other treatment modalities. Detoxification 
episodes are often hospital based and may begin 
with emergency treatment of an overdose. 
However, clinicians generally advocate that, 
because of the narrow and short-term focus and 
very poor outcomes in terms of relapse to drug 
dependence, detoxification not be considered a 
modality of treatment in the same sense as 
methadone, TCs, outpatient nonmethadone, and 
CD programs. 

Much drug detoxification (an estimated 100,000 
admissions annually) is now taking place in 
hospital beds. It is doubtful that hospitalization 
(especially beyond the first day or two) is 
necessary in most cases, except for the special 
problems of addicted neonates, serious sedative 
dependence, and concurrent medical or severe 
psychiatric problems, and for clients with a 
documented history of complications or flight. In 
this committee's judgment, detoxification may be 
undertaken successfully in most cases on a 
nonhospital residential, partial day care, or 
ambulatory basis. 



Variations in Effectiveness of Programs 
Within Modalities 

Effectiveness measurement was a critical early 
issue in the development of the drug treatment 
system. Data from the 1970s indicated that client 
retention and discharge status varied significantly 
across geographic areas. Aside from methadone 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



studies, however, there is no published literature 
examining whether these differences were 
systematically related to client characteristics or to 
differences in the therapeutic process— or, indeed, 
whether such variations might be expected to occur 
as a result of chance. 

Studies of methadone treatment indicate that 
program characteristics such as inadequate 
methadone dosage levels, staff turnover rates, and 
differences among counselors (which are not fully 
defined) are significantly related to differences in 
client performance while in treatment. Currently, 
however, program effectiveness measures are 
virtually unused in the management of the 
treatment system. 



Treatment in Prisons 

About 30 percent of state prison inmates report 
drug consumption patterns serious enough to 
indicate a need for treatment. According to the 
most recent (1986) sample survey of state 
penitentiaries, 15 percent of all inmates reported 
some episode of voluntary drug treatment while in 
prison (during the individual's current or previous 
confinement). At least two-thirds of prison 
treatment episodes are probably equivalent to the 
outpatient nonmethadone modality— periodic 
individual or group therapy sessions. The other 
episodes are similar to stays in a therapeutic 
community, including separation from the general 
prison population for the expected 6 to 12 months 
until graduation from the program. 

Because the correctional system has custody of so 
many individuals in need of treatment, it would 
seem to be an important site for drug treatment 
programs, and numerous such programs have been 
established at various times over the years. Most 
prison drug treatment programs studied, including 
specialized "boot camp" or "shock incarceration" 
facilities, have not reduced the typically high 
postrelease rates of recidivism (return to criminal 
behavior) among untreated prisoners. However, a 
small number of controlled prospective studies of 
well-established prison TCs with strong linkages to 



community-based treatment programs indicate that 
prison TCs can reduce the treated group's rate of 
rearrest by a worthwhile margin. These studies 
also yield, within the treated group, the strong 
correlations between outcome and length of 
retention in treatment that are found in studies of 
community-based modalities. 



Costs and Benefits of Treatment 

There is qualified evidence that methadone 
maintenance, therapeutic communities, and 
outpatient nonmethadone treatment are cost- 
beneficial. The qualification is necessary because, 
first, there have been very few cost/benefit studies; 
second, although those performed have been 
consistent in finding positive results, they have not 
been derived from fully controlled clinical trials 
but rather from controlled observational studies. 

Methadone treatment, when implemented at the 
resource levels observed in the late 1970s, 
provides individual and social benefits over a term 
of at least several years that are substantially 
higher than the costs of delivering this treatment. 
The benefits of TC treatment are also substantial, 
but the short-term costs are higher than those of 
methadone treatment, yielding generally somewhat 
lower benefit/cost ratios but ones that still favor 
the use of this treatment. The benefits of 
outpatient treatment are smaller than those of 
methadone or TC treatment, but the cost of the 
treatment is low and the yields thus are favorable. 
There are no cost/benefit analyses for chemical 
dependency programs, detoxification, or prison- 
based treatment. 



Comparison of Data on Effectiveness 

and Expenditures 
for the Major Treatment Modalities 

Table 5-6 summarizes, for the four principal 
treatment modalities, the type and amount of 
available treatment effectiveness data, from the 
most rigorously conducted randomized clinical 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



trials, 2 to natural experiments, to controlled 
observation studies using multivariate analysis (the 
DARP and TOPS), to simple studies of treatment 
cohorts with limited comparisons and analyses. 
Methadone has received far more analysis than any 
other modality, followed by therapeutic 
communities and outpatient nonmethadone. 
Chemical dependency programs have had by far 
the least study. 

In contrast to the weight of the effectiveness data 
are the numbers of clients treated by different 
modalities and the annual revenues (discussed 
more extensively in Chapter 6). Chemical 
dependency is the treatment modality with the 
highest revenues, probably the second largest 
number of clients, and the smallest scientific basis 
for assessing its effectiveness. Outpatient 
nonmethadone programs treat more clients than all 
other modalities combined, and although there 
have been two major studies (DARP and TOPS) 
that examined the effectiveness of multiple 
programs, the literature on this modality does not 
adequately deal with the diversity of treatments 
and client differences subsumed in this category. 
Methadone maintenance has been studied much 
more extensively than any other modality, has the 
smallest annual revenues of the four major 
modalities, and is appropriate only for long-term 
treatment of opiate-dependent individuals. 
Therapeutic communities have been studied much 
more than outpatient nonmethadone programs but 
substantially less than methadone programs. 



The scientific attractiveness of clinical trials of a treatment 
versus a placebo or of treatment A versus treatment B is clear 
in principle, but such trials have proven very difficult to conduct 
with the major modalities of drug treatment. The modalities are 
quite different (and therefore hard to make "blind" to clients or 
clinicians), require extended duration (creating attrition 
problems), involve reluctant and socially troubled clients 
(leading to difficulties in achieving random assignment, 
compliance, and retention), and deal with complicated 
prognoses, especially owing to the chronic, relapsing nature of 
the problem (creating problems of participant selection, 
measurement, and comparability). 



Needs and Priorities for Research on 
Treatment Methods and Services 

Research on drug treatment is a core responsibility 
of the National Institute on Drug Abuse (NIDA) 
and has been a roughly constant proportion of 
NIDA's program for a number of years. NIDA's 
total research funding declined by nearly half in 
real terms from 1974 to 1983, but it has greatly 
increased since then and is projected to reach triple 
the 1983 level in 1990. 

Major treatment research questions that need to 
be addressed for the major modalities of public 
treatment are the following: What client and 
program factors influence treatment-seeking 
behavior, treatment retention and efficacy, and 
relapse after treatment? How can these factors 
be better managed? Treatment-seeking factors 
include community outreach, family and employer 
interventions, and program intake and triage 
procedures. Retention and efficacy factors include 
optimal durations and schedules, pretreatment 
motivations, counselor or therapist behavior, 
incentives and conditions of employment, clinic 
procedures, criminal justice contingencies, and 
ancillary services. Posttreatment factors include 
relapse prevention interventions, abstinence 
monitoring, and environmental reinforcement. 

Despite the difficulties of maintaining the integrity 
of controlled experiments in treatment programs, 
these studies provide the most incontrovertible 
evidence about comparative treatment effects, and 
efforts to conduct them should be strongly 
encouraged. A more detailed understanding of 
treatment processes through ethnographic and case 
study methods is also badly needed. This work is 
the basis for the design and interpretation of 
survey instruments. 



Studies should be initiated within as well as 
across each major treatment modality to answer 
the following question: What are the relations 
of treatment performance (that is, differential 
outcomes, taking initial client characteristics 
into account), the content and organization of 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



treatment (specific site arrangements, service 
offerings, therapeutic approaches, staffing 
practices), and the costs of treatment? 

Health services research is a critical element in 
building treatment systems. An important 
foundation for services research as well as 
program accountability is the development, 
maintenance, and analysis of a system of data 
acquisition on treatment programs and client 
performance. Results from these kinds of studies 
will permit more fully optimal, cost-effective 
selection of facility quality, staff salary and 
training levels, services coordination methods, 
intensity of services, and other components. 

Systems of this sort were established in the 1970s 
but were effectively disassembled as a matter of 
federal policy in the 1980s. Treatment data 
acquisition systems must be rebuilt and 
effectively managed and utilized if the 
improvement of treatment knowledge and 
practice is to be evaluated and facilitated in the 
1990s. Data on treatment effectiveness and 
costs should become the cornerstone of decisions 
about treatment coverage by public and private 
programs. 

Chemical dependency programs are the least well 
studied of the drug treatment modalities. The 
aggressive marketing that many such programs 
have deployed has created suspicion about these 
programs in many quarters that cannot be allayed 
without investment in objective treatment research 
and evaluation. The optimal site of delivery and 
length of programming, including the duration of 
intensive treatment and aftercare periods, and the 
inclusion of specific therapeutic elements need to 
be more closely investigated. 

Only a few chemical dependency treatment 
providers have played positive roles in providing 
data and research opportunities for effectiveness 
studies; many more need to do so in order to 
answer these questions: What is the 
effectiveness of chemical dependency treatment 
for drug-impaired clients of varying 
characteristics? Are there variations in 



program effectiveness, and if so, why? What 
are the actual costs and benefits of the most 
effective components of chemical dependency 
treatment? 

The major efforts to date to investigate treatment 
efficacy occurred prior to the epidemiological 
reemergence of cocaine in the 1980s. There is 
reason to believe that some findings about 
treatment modalities— such as the importance of 
time in treatment—will prove robust in the face of 
changing drug markets, but others may not. The 
infrastructure of treatment research centers 
decayed during the stagnation of drug research 
funding, and as this capability is rebuilt, it 
should specifically address the following 
questions about cocaine treatment: What are 
the most effective treatment elements for 
cocaine dependence and abuse? To what degree 
can current modalities be effective for crack- 
cocaine? What new or existing pharmacological 
and nonpharmacological treatment elements can 
improve the clinical picture? 

The majority of individuals in treatment are young 
adult males (20 to 40 years old), and their 
responses dominate treatment research statistics. 
The major findings of research to date on the 
effectiveness of different modalities and elements 
of treatment seem to apply roughly as well to 
adolescents and women with young children 
(including pregnant women) as to the more 
prevalent demographic groups. However, the 
potential significance of child-rearing/ child-bearing 
women and young clients in terms of the future 
benefits of present treatment (or future costs of 
present nontreatment) is great. Research plans in 
all areas need to devote special attention to 
differentiated knowledge about these populations. 
The committee recommends that a special study 
initiative be undertaken by the National Institute on 
Drug Abuse, in conjunction with other relevant 
agencies of the Public Health Service, on the 
treatment of drug abuse and dependence among 
adolescents and women who are pregnant or 
rearing young children. 



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SUMMARY 



THE TWO-TIERED STRUCTURE OF 

THE TREATMENT SYSTEM 

(CHAPTER 6) 

There are two highly contrasting tiers of treatment 
programs—a public and a private— distinguished 
fundamentally by their mode of financing. This 
distinction generates and sustains differences in 
clientele, services offered, and current readiness to 
accommodate new admissions. 

As reported in a 1987 survey, the public tier 
supplied 636,000 treatment episodes with revenues 
of $791 million, about four-fifths financed by 
public funds; it comprised largely not-for-profit 
and some publicly owned outpatient clinics (2,434 
nonmethadone and 267 methadone), more than 900 
residential programs, 159 public hospitals, and 72 
prison programs (see Table 6-1). This tier served 
mostly indigent clients, and in high-prevalence 
parts of the country it was at or above effective 
capacity. 

The public tier was developed about 20 years ago 
with federal leadership, a role that has largely 
shifted to the states, few of which have come close 
to covering the big reductions in federal 
contributions that have taken place since 1975. 
This tier continues to treat as many individuals as 
in the past but with less adequate facilities, 
services, and personnel. It is operating short of 
current demand in some but not all parts of the 
country. 

The private tier in 1987 supplied 212,000 drug 
treatment episodes with revenues of $521 million, 
three-fourths from privately paid fees and 
reimbursements; it comprised 801 proprietary and 
not-for-profit hospital programs (offering in almost 
all cases chemical dependency treatment), 331 for- 
profit outpatient programs, 76 proprietary 
residential programs, and 67 methadone programs. 

The private tier treats mainly insured working 
class, middle class, and upper class cocaine and 
marijuana clients (within a larger program serving 
mostly alcohol clients); in most instances it has 
been treating drug cases for less than 10 years and 



has grown very rapidly. Per diem charges in 
private-tier outpatient programs (methadone and 
nonmethadone) appear similar to those in the 
public tier, but residential and hospital per diem 
charges are three to four times greater. The 
private tier reports abundant reserve capacity. 

In 1987, reports of reserve treatment capacity were 
highest (more than 50 percent above the current 
census) in private and public hospitals and in 
private-tier residential facilities; reserve capacity 
was lowest in public-tier methadone and outpatient 
facilities. There were substantial regional 
differences in public-tier availability; when these 
are taken into account, it appears that some areas 
of the country are sorely pressed for public 
residential treatment as well. 

There is a need to selectively expand the public 
tier— but with a very important reservation. The 
current resource intensity of the public-tier 
programs is marginal at best. Expansion will 
almost certainly reduce and dilute this intensity 
unless aggressive measures are instituted. The 
need for more resource-intensive treatment appears 
equal in importance to the need for increases in 
capacity. Research data on returns to more 
intensive resources per patient are scarce, but the 
most sensible course is to increase public resources 
to restore earlier levels of service intensity, facility 
quality, and staff skills, as well as to increase the 
capacity for new admissions. 

In selected regions, the public tier needs greater 
investments in both intensity and capacity. The 
private tier appears at this time to be heavily 
committed to acute care hospital treatment for 
cocaine and marijuana problems and may benefit 
most from either a shift toward greater use of 
nonhospital residential and outpatient modalities 
or, if such a shift cannot be effected, a move 
toward cost or charge structures that will permit 
and encourage the more extended periods of care 
typical of these modalities, in contrast to the short 
stays and high per diem charges now characteristic 
of hospital-based chemical dependency treatment. 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



PUBLIC FINANCING OF DRUG 
TREATMENT (CHAPTER 7) 

The Goals and Priorities of Public Coverage 

Two basic principles justify public coverage of 
drug treatment, and these principles in turn suggest 
specific priorities for the expansion of the public 
tier that is now under way largely as a result of the 
recent federal anti-drug legislation. The first 
principle is that public coverage should seek to 
reduce external social costs—in particular those 
relating to crime and family role dysfunctions. 
The second principle is that public coverage should 
remedy constraints arising from inadequate 
income. Based on these principles, the general 
goal of public coverage should be to provide 
adequate support for appropriate and timely 
admission, as well as completion or 
maintenance, of good-quality treatment for 
individuals who cannot pay for it (fully or 
partly) whenever such individuals need 
treatment, according to the best professional 
judgment, and seek treatment or can be induced 
through acceptable means to pursue it, 
assuming there is some probability of positive 
response. 

The committee estimates that 35 million 
individuals qualify as indigent with regard to 
private purchase of any form of drug treatment; 
that is, they are neither adequately insured nor 
able to pay out of pocket for appropriate forms of 
specialized treatment if needed and thus would 
have to rely on public services. For residential 
drug treatment, the committee's estimate of those 
who are unable to afford it if needed rises to 60 
million. 

The resources still needed to achieve the general 
goal of public coverage represent a major increase 
in public support for treatment, and even under the 
current conditions of extraordinary public concern 
about the drug problem and the possibility of 
commensurate appropriations, everything cannot 
be done at once. Priorities for treatment thus need 
to be defined. The committee recommends the 
following priorities for public-tier expansion: 



■ end delays in admission when treatment is 
appropriate, as evidenced by waiting lists; 

■ improve treatment (by raising the levels of 
service intensity, personnel quality and 
experience, and retention rates of existing 
modalities; by having programs assume 
more integrative roles with respect to 
related services; and by instituting 
systematic performance monitoring and 
follow-up); 

■ expand treatment through more aggressive 
outreach to pregnant women and young 
mothers; and 

■ further expand community-based and 
institutionally based treatment of criminal 
justice clients. 

The upgrading of performance and quality levels 
is intrinsic to the other three priorities and would 
be needed even if expanded treatment admissions 
were not an objective. The recent decade-long 
hollowing-out of treatment programs through 
resource attrition, together with research findings 
about substantial variations in program 
performance, and the consistent importance of 
retention in predicting outcome all support the 
need for restoration of funding and quality levels 
in treatment. 

The upgrading of staff capabilities and morale and 
modest but critically needed renovation of decrepit 
facilities and furnishings have multiple 
significance. Good staff morale and decent 
facilities increase the attractiveness of treatment 
programs and thus their ability to recruit and retain 
staff. These factors also affect client interest in 
program admission and retention. Most critically, 
the competence, quality, and continuity of care 
givers may well be a critical element in explaining 
the differential effectiveness of treatment 
programs. 

It is possible to estimate the amount of new public 
financing needed to meet these priority objectives, 
although to do so, key assumptions must be made 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



about such parameters as capital costs, training 
expenses, and the number of individuals who could 
be induced to enter treatment at various levels of 
effort. The committee judges that the amount 
needed to upgrade and expand the drug 
treatment system, beyond current spending 
rates, is $2.2 billion in annual operating costs 
(plus $1.1 billion in one-time costs) for a 
comprehensive plan, $1 billion annually (plus 
$0.5 billion up front) for a core plan, or $1.6 
billion annually (plus $0.8 billion in up-front 
costs) for an intermediate plan. Details are 
provided in Table 7-1. Because data supporting 
the costs of the recommended strategies are 
uncertain, it is essential that relevant data 
collection be developed very quickly and its 
products analyzed as soon as possible. 

The committee's recommended strategies lead to a 
consideration of needed changes in how to manage 
the public tier. These issues divide into the 
following: the roles and interrelations of the 
states, the federal government, and public-tier 
providers; the most appropriate shorter and longer 
term financing mechanisms for providing public 
support (direct service programs versus public 
insurance); and the controls needed to make the 
most effective and efficient use of public funds. 



Federal and State Roles 



State governments have played the major role in 
financial administration and quality control of drug 
treatment programs in recent years, but there has 
also been cyclical movement between state and 
federal leadership. The federal government 
originally built most of the public tier of providers 
and then transferred responsibility for regulating 
and supporting this tier largely to the states; it is 
now moving back into the lead role. This 
expansion of federal support should be 
accompanied by more active, centralized direction 
and control of treatment resources. 

States will continue to have the major operational 
responsibility for implementing new drug treatment 



priorities and standards. The increasing streams of 
federal monies must be allocated so as to help 
support the critical data collection, training, and 
technical assistance functions to be deployed 
through state offices. In the recommended 
expansion of support, it is appropriate for the 
federal government to take the lead in the short 
term in upgrading program quality and extending 
outreach to critical populations. In so doing, there 
are two important near-term management 
objectives. One objective is to ensure the most 
efficient and effective expenditure of existing and 
incremental funds, preserving as much discretion 
as possible on the federal level so that federal 
agencies have the flexibility to encourage states to 
reach the new goals. The second objective is to 
maximize coordination with other anti-drug abuse 
activities (including public safety, justice, and 
correctional institutions) and other social welfare 
and health services. 

In lieu of fixed formulas for the allocation of funds 
received by the states (which, as most recently 
revised, are based on population weighted 
somewhat by degree of urbanization), the 
committee recommends that state agencies be 
required to submit plans that analyze the 
conjunctions and mismatches among the most 
current epidemiological information and known 
treatment capabilities; it further recommends 
that the states be required to propose annual 
spending patterns that reflect this information. 
In addition, a portion of the federal dollars must 
go into technical assistance and data system 
building to ensure at the state, local, and program 
levels that this planning effort will have a factual 
basis. 

One other notable element of the federal role is 
support for veterans. The Veterans Administration 
has previously targeted drug programs for drastic 
budget reductions in order to meet overall fiscal 
limitations. At the very least, outpatient or 
residential drug treatment services—furnished 
directly or by contract— should be made available 
to meet the needs of former inpatients. 



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Mechanisms for Providing Public Support 

At present, the public sector provides access to 
drug treatment through two distinctly different 
financial mechanisms: direct program financing 
through service contracts and grants to formally 
defined and certified addiction treatment programs, 
versus individual insurance financing through 
Medicaid and similar programs. The largest and 
most important guarantee of access to drug 
treatment is the program of public grants or 
contracts with public-tier treatment providers, who 
serve virtually all of the medically indigent 
population (the poor, uninsured, or underinsured) 
needing drug treatment. Continued expansion of 
the dollar level of this form of support is the 
primary means recommended by the committee to 
address public coverage goals and priorities over 
the next 5 years. 

Emphasis on direct service is an appropriate model 
for directed system building, but long-term system 
maintenance may be better served by a 
proportionately greater use of public insurance 
financing, supplemented by direct service grants to 
ensure critical program elements such as outreach 
and other important services to the many 
individuals for whom low income is not the only 
barrier to seeking and responding well to 
treatment. The ground should be prepared to 
"mainstream" drug treatment more fully in the 
next 5 to 10 years, incorporating it as much as 
possible into public health care insurance for the 
poor, that is, the set of state programs presently 
gathered under the tent of federal Medicaid. 

Currently, eligibility for Medicaid among poor 
people is sharply circumscribed for those between 
the ages of 18 and 65 who are not permanently 
disabled. There are large gaps in eligibility in the 
health insurance programs of the 50 states and the 
District of Columbia, all of which participate in 
the federal Medicaid matching program. Medicaid 
does provide significant health care coverage for 
low-income women (especially if they are 
pregnant) and their children who are less than 18 
years old (especially if the children are less than 6 
years old). All states, however, exclude 



nondisabled single men from coverage, and there 
is great variation across states in the family income 
ceilings for Medicaid eligibility, which can be and 
often are well below the federal "poverty line." 

Fewer than a handful of states with the broadest 
eligibility and benefits now account for a large 
majority of all Medicaid support for drug 
treatment. Yet even in these states, the programs 
cover only some of the services needed in—or 
adjoined with—drug abuse treatment (e.g., medical 
examination at intake, visits for methadone 
dispensing, hospital-based services), and payment 
levels are often much lower than the cost of 
covered services. 

There are five steps that would be particularly 
useful as incentives toward a larger role for 
Medicaid in treating drug problems and that 
would not compromise the efficiency of the 
direct service support mechanism. The first 
step is to require all parties to cooperative 
agreements, grants, or contracts involving 
federal funds to develop and display evidence of 
progress toward the long-term goal of increasing 
the receipt of funds from the Medicaid system. 
Examples of potential strategies include facilitating 
the registration of clients eligible for Medicaid 
benefits and meeting relevant accreditation 
standards familiar to Medicaid, such as those of 
the Joint Commission on Accreditation of 
Healthcare Organizations or the Commission on 
Accreditation of Rehabilitation Facilities. 

The second useful step is to begin stipulating 
matching requirements rather than 
maintenance-of-effort requirements for increases 
in grant support to the states. By determining 
the matching ratio with the same formula used to 
determine Medicaid matching, the incentive to 
states to use Medicaid structures will be increased, 
and the disincentive— states must match every new 
Medicaid dollar but can get more block grant 
dollars without increasing state appropriations— will 
be removed. 

The third step is for the federal government to 
require state Medicaid programs to include drug 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



treatment as part of the standard package of 
benefits offered to all current (and any newly 
added) Medicaid-eligible persons. The drug 
benefit package should cover methadone treatment, 
outpatient nonmethadone treatment, and residential 
treatment in state-accredited freestanding 
(nonhospital) as well as hospital-affiliated 
residential facilities and outpatient programs. No 
special copayments or limitations— that is, no 
copayments or limits not generally applicable to 
medical/surgical benefits— should be applied to 
drug treatment. For those states with private 
insurance mandates for drug treatment insurance 
coverage, the Medicaid drug treatment benefit 
should be at least as comprehensive as (which does 
not mean identical with) the mandated private 
insurance benefit. 

The fourth step is to reduce gross inconsistencies 
in the way drug problems are handled in 
eligibility determinations for Medicaid, Aid to 
Families with Dependent Children, Medicare, 
Supplemental Security Income, and other 
income maintenance, education, and housing 
assistance entitlement programs. These 

inconsistencies create a bureaucratic nightmare for 
the drug treatment programs and state agencies 
that draw on more than one such source of funds— 
which most of them try to do. The Office of 
National Drug Control Policy should analyze 
definitional inconsistencies among federal 
programs and lay out a plan to minimize resulting 
problems. 

The fifth step is to develop a thoroughgoing 
system of public utilization management (a term 
describing arrangements to define access to 
effective treatment while keeping costs at 
efficient levels). Good utilization management 
works to ensure that a fully appropriate and 
needed range of services is used and that different 
service components are coordinated. Many of the 
components of such a system were developed in 
the early 1970s but subsequently disestablished. 
These components are described in the next 
section. 



Utilization Management 

The most fundamental principle of utilization 
management is that access to and utilization of care 
should be controlled and managed on a case basis 
by "neutral gatekeepers" or central intake 
personnel (although this triage or central intake 
function may need to be dispersed geographically). 
These personnel should be regulated by 
certification standards and undergirded by time- 
limited, performance-accounted licenses and 
contracts. Client assessment, referral, and 
monitoring of progress in treatment should be 
reviewed (or performed) independently of the 
treatment provider. These personnel should have 
appropriate clinical credentials that include the 
understanding that longer residential and outpatient 
durations are strongly correlated with beneficial 
results among public clients. Effective utilization 
management should recognize that drug abuse 
and dependence are chronic, relapsing disorders 
and that for any one client, more than one 
treatment episode may be needed and different 
types of treatment may need to be tried. 
"Gatekeepers" should have access to ongoing 
performance evaluation results and 
responsibility for implementing cost-control 
objectives. 

There should be rigorous preadmission and 
concurrent review of all residential drug treatment 
admissions, and especially of hospital admissions, 
and concurrent review of outpatient treatment. 
Unlike the objective in utilization management of 
acute hospital care for most medical conditions, 
which is basically to hold inpatient lengths of stay 
to a minimum, the objective for drug treatment 
services should be to increase client retention in 
appropriate, cost-efficient treatment settings. 

The major cost-control concern in this area is the 
use of high-cost treatment when lower cost 
alternatives could be as effective. This hazard 
attaches principally to acute care hospital inpatient 
services for detoxification or rehabilitation 
treatment. The public tier generally has not been 
heavily invested in hospital-based drug treatment, 
and this should continue to be the case—but not as 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



a matter of rigid exclusion. The committee 
recommends that hospital-based drug services 
be reimbursed at the same level as nonhospital 
residential treatment rates, unless there is 
evidence that a client specifically requires 
continuing acute care hospital services. 
Hospital-based drug detoxification should only 
be covered in the event of medical complications 
such as those noted below or the lack of 
appropriate residential or outpatient facilities 
nearby. Indications for hospital-based inpatient 
drug detoxification are the following: 



ongoing services research and data collection in 
other government agencies and units concerned 
with drug problems (see the discussion of research 
needs in Chapter 5). Certification for public 
support should be time limited and based on 
performance— especially client retention and 
improvement— rather than on process standards. 
Performance is to be demonstrated by outcome 
evaluation, and the standards of performance 
adequacy should be informed by past and ongoing 
treatment effectiveness research on retention and 
outcomes. 



serious concurrent medical illness 
such as tuberculosis, pneumonia, or 
acute hepatitis; 

history of medical complications such 
as seizures in previous detoxification 
episodes; 

evidence of suicidal ideation; 

dependence on sedative-hypnotic 
drugs as validated by tolerance testing 
(therapeutic challenge) to determine 
the appropriate length of stay; and 

history of failure to complete earlier 
ambulatory or residential 
detoxification versus completion in 
inpatient settings. 



As perhaps the most important and immediately 
needed utilization management requirement, the 
committee recommends that all drug treatment 
programs receiving public support be required 
to participate in a client-oriented data system 
that reports client characteristics, retention, and 
progress indicators at admission, during 
treatment, at discharge, and (on a reasonable 
sampling basis) at one or more follow-up points. 
There should be periodic, independent 
investigation on a sampling basis of the quality and 
accuracy of the data system or systems, and the 
systems should be designed to dovetail or link with 



PRIVATE COVERAGE OF DRUG 
TREATMENT (CHAPTER 8) 

Extent, Costs, and Trends of Coverage 

The private tier of drug treatment providers is 
largely oriented toward treating the employed 
population and their family members. The 
majority of this population, about 140 million 
individuals, have specifically defined coverage for 
drug treatment in their health insurance plans. 
About 48 million others who are privately insured 
do not have specifically defined coverage for drug 
treatment, although coverage may occur de facto 
under general medical or psychiatric provisions. 
As of 1988, the health plans of about 67 percent of 
full-time employees of firms with 100 or more 
employees offered specifically defined coverage 
for some types of drug treatment, although the 
actual extent of benefits under these defined 
coverage provisions is uncertain. 

Actuarial studies of claims experience yield rather 
modest estimates for the overall cost of covering 
drug treatment. Drug treatment expenditures tend 
to be buried under more inclusive headings and 
behind "horror stories" involving troubled 
adolescents with multiple diagnoses spending 
months in psychiatric facilities. Nevertheless, the 
committee estimates that a health plan with typical 
coverage now spends 1 percent or less of its total 
outlays for explicit drug treatment, most of it for 
hospital inpatient charges— with a large fraction of 
that cost devoted to detoxification. There has been 



20 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



a substantial apparent growth in the rate of drug 
treatment claims in recent years, although it is 
unclear how much of this increase is due to more 
revealing or accurate drug problem diagnoses 
versus increased demand for drug treatment. 

Although this growth is disturbing to the degree it 
increases the aggregate cost of health insurance 
premiums, it is desirable if it means that more of 
those who need treatment are seeking and 
receiving it, particularly if the treatment delivered 
is appropriate, effective, and reasonable in cost. 
Some payers, however, reacting in part to the high 
costs of a small number of cases and the high 
incidence of recidivism, have strongly questioned 
the value of drug treatment episodes, and they 
have moved to differentially limit reimbursement 
of drug treatment to help trim increasing overall 
costs. 



of treatment by favoring inpatient stays of 
prespecified lengths. 

The committee believes that the development of 
soundly derived standards for admission, care, 
and program performance will do more at this 
time to generate appropriate coverage than a 
further set of mandates. If mandates are to be 
used, efficiency and fairness dictate that they be 
applied to all competing insurers. Yet if the 
private market leaves large numbers of the insured 
population without coverage for drug treatment, it 
may be necessary for government to intervene. 
Such action could involve subsidies for drug 
treatment coverage, tax preferences for certain 
kinds of coverage, or mandates, with the choice 
dependent on judgments about the incidence, 
efficiency, and equity of alternative ways of 
financing coverage. 



Mandating Drug Treatment Coverage 

There are legislative mandates in 18 states plus the 
District of Columbia requiring that certain 
categories of employer-supplied group health plans 
specifically cover— or offer optional coverage for— 
drug and alcohol treatment. (Another 19 states 
require some degree of coverage for alcohol 
treatment only.) In the committee's judgment, 
private coverage of drug treatment is beneficial to 
individuals and employers and should be included 
in every health package; however, legislative 
mandates at the state level have not necessarily 
proved to be an effective way, and are clearly not 
the only way, to induce adequate coverage. Most 
insured individuals whose plans include explicitly 
defined coverage for drug treatment reside in states 
that do not have legislative mandates for such 
coverage. Moreover, the political process has 
often produced less-than-optimal mandatory 
provisions that are difficult to adjust, overly rigid, 
and pay too much attention to limits on the length 
of stay and the number of visits rather than to the 
cost and effectiveness of treatment. Most 
mandatory provisions have the constraining effect 
of funneling people toward one particular modality 



Optimal Coverage Provisions 

Private insurance provisions (including most 
legislatively mandated benefits) often include 
financial incentives for beneficiaries to seek more 
expensive hospital or residential treatment. 
Although residential drug treatment, including 
hospital treatment, often serves clinically important 
functions such as permitting intensive therapy and 
isolating the patient from an adverse environment 
or treating concurrent psychiatric or medical 
complications, hospital-specific components (e.g., 
24-hour onsite medical coverage) do not seem to 
be the therapeutically important elements in drug 
treatment programs that are sited there, even 
though the availability of these components is used 
to justify charging acute care hospital rates for all 
clients. 

The committee recommends that curbs on unit- 
of-service costs for inpatient care be 
strengthened and that payers insist on the 
generation of reliable performance/outcome 
data. Drug treatment services at hospital sites 
should be reimbursed separately from other 
diagnoses or hospital services; there appears to 
be no compelling reason why these services for 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



21 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1 



most drug treatment patients should routinely 
command fees comparable to acute care rates 
rather than to reasonably competitive residential 
treatment rates. 

Insurers and employers need to become better 
informed about drug treatment and to structure 
their benefits to support controlled access to a 
broad range of the most appropriate, effective, and 
efficiently priced treatments rather than to a 
narrow (and expensive) band of options that are 
similar in form to the treatment of acute medical 
conditions. Private plans should cover 

appropriate, adequate, cost-effective drug 
treatment and not reimburse the cost of excessive, 
inappropriate treatments or charges (see Table 8-2 
for placement guidelines). 

The committee recommends that private risk 
bearers, in lieu of arbitrary payment caps or 
exclusions, institute rigorous, independent 
preadmission review (where possible) and 
concurrent review of all hospital and residential 
admissions as a way to control access and 
utilization, ensure appropriate placement, and 
manage costs. Preadmission review may not be 
necessary for such admissions, but early 
concurrent utilization review is important for such 
treatment to ensure that diagnostic criteria are 
observed and charges are reasonable. Employee 
assistance programs can serve as utilization 
managers in cases in which their personnel have 
appropriate training for matching patients to 
treatment. Hospital utilization should be managed 
under the same terms as those recommended for 
public coverage (see the section on utilization 
management in Chapter 7). 

The committee further recommends that private 
payers insist that providers participate in and 
agree to the publication of regular, independent 
follow-up surveys to determine client outcomes, 
taking into account data on admission 
characteristics such as problem severity. 
Providers and payers should be able to compare 
treatment results with overall program norms to 
ensure the maintenance of good performance and 



the identification of poor performance when it 
occurs. 

The committee recommends that the provisions 
of drug treatment benefits, including 
deductibles, copayments, stop-loss measures, 
and scheduled caps, be similar to provisions for 
treatment of other chronic, relapsing health 
problems. Except in terms of limitations on the 
length of stay and number of visits, such 
provisions are mostly the rule today. Sound 
utilization management that includes reliable 
performance and outcome measurements is likely 
to obviate the need for separate length-of-stay and 
dollar caps on coverage. Nonhospital residential 
and outpatient treatment delivered in state-certified 
treatment programs should be covered. Coverage 
limitations, charge schedules, and cost-containment 
incentives (e.g., copayment schedules) should be 
adjusted to reflect the findings of research on 
appropriate models, lengths, and costs of drug 
treatment—especially the recognition that longer 
residential and outpatient stays are strongly 
correlated with more beneficial results. 



CODA 

The drug problem is not a fixed constellation but 
a restless, ever-changing composite. Within this 
pharmacological and sociological diversity, 
treatment addresses the chronic, relapsing 
disorders of drug dependence and abuse. The best 
treatment interventions have been shown to 
"work"— reversing drug-seeking behavior, related 
criminal activity, and other dysfunctions— only 
partially; that is, the different treatment methods 
encourage recovery from these imperfectly 
understood disorders to a greater or lesser degree. 
Moreover, each modality of treatment can attract 
and affect only some of the people in need. 

Success in treatment is not guaranteed and is often 
not complete, but even if it managed to be both, 
there would still be a major problem: most people 
who need treatment seek it only reluctantly, after 
failing at self-help, after much harm has been 
done, and after much pressure— interior and 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



SUMMARY 



exterior—has been brought to bear. However, as 
with heart disease and cancer in the health domain, 
theft and assaultive behavior in the realm of 
violent crime, or homelessness and family 
dissolution in the area of social welfare, the lack 
of a panacea does not excuse society from 
responding to the best of its ability. The overall 
costs of drug problems are so high that reducing 
them even modestly is worthwhile. The committee 
is persuaded that the treatment methods available 
today can at least potentially realize benefits that 
well exceed the costs of delivering these services. 
Treatment makes sense on the grounds of utility as 
well as humanity. 

The treatment system should do a better job of 
knowing itself and acting on that knowledge. 
Much of the knowledge gained in the past about 
the elements and optimal costs of effective 
treatment was brushed aside in the 1980s in the 
zeal to cut public spending and increase private 
revenues. In the 1990s, a different perspective 
seems to be gaining ground. Solutions to the 
challenge of improving drug treatment can be 
achieved if current financial trends continue and if 
leaders of the public and private tiers of drug 
treatment bend their efforts to the modest but 
necessary task of making the system learn its 
lessons. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 23 



CHAPTER 1: INTRODUCTION 



A provision in the Anti-Drug Abuse Act of 1986 
instructed the secretary of health and human 
services to seek an independent study of substance 
abuse treatment coverage. The study was 
mandated to report on the extent and adequacy of 
financing—public and private— for treating and 
rehabilitating drug abusers and to make 
recommendations as needed. 1 It seemed likely that 
the study might identify unmet needs for new 
federal action. For example, the state-level 
components of the national drug treatment system 
had been cast adrift in the 1980s from earlier, 
more restrictive federal controls, and the system's 
ability to help communities respond to new 
challenges, such as the crack-cocaine epidemic, the 
acquired immune deficiency syndrome (AIDS) 
epidemic, and the growing violence of drug 
markets, appeared tenuous. What was not clear 
was what to do about the situation. 

This volume is the response to the congressional 
charge, fulfilling an agreement, finalized in 
December 1987, between the National Institute on 
Drug Abuse and the Institute of Medicine. It is 
the outcome of an Institute of Medicine/National 
Academy of Sciences committee process that 
included reviews of the scientific literature, 
specially commissioned papers (to be published in 
a separate volume), field visits to cities around the 
country, conferences and correspondence with 
experts in many relevant fields, and application of 
the expertise accumulated by committee members 
and staff in their own professional work. 

The operational questions the committee has tried 
to answer are tempered versions of the 
congressional mandate: Is it good policy to invest 
as much— or as little— of society's pooled resources 
(basically, public programs and private insurance) 

'The operative language of the law (P.L. 99-555, section 6005) 
reads: . .the Institute of Medicine of the National Academy 
of Sciences [is] to conduct a study of (1) the extent to which 
the cost of drug abuse treatment is covered by private 
insurance, public programs, and other sources of payment, and 
(2) the adequacy of such coverage for the rehabilitation of drug 
abusers. . . . The report shall include recommendations of 
means to meet the needs identified in such study." 



in drug treatment as is now being invested? And 
if this much expenditure— or more— is truly 
necessary and worthwhile, how can these dollars 
be spent most prudently and equitably, with the 
highest likelihood of yielding good results? 

The committee's overall conclusion is that it is a 
"good bet" to put more resources into drug 
treatment. Public expenditures should be 
increased, especially at the federal level, to 
support the most carefully validated treatment 
modalities, as well as to improve clinical training 
and facilities, treatment research activities, and 
program evaluation and management systems. 
Public funding should focus on boosting the 
average quality of treatment as well as the number 
of program admissions, with special emphasis on 
increasing treatment opportunities for those under 
criminal justice supervision and for pregnant 
women or women who care for young children. 
In the private sector, coverage policies should be 
revised. Insurers should institute better control 
over tendencies toward preferential reimbursement 
of an increasing number of high-cost treatment 
episodes. They should also encourage more 
widespread reimbursement and utilization of less 
expensive facilities and programs, under 
comprehensive systems of utilization review based 
on performance evaluation. 

These conclusions appear straightforward, but they 
did not in fact come quickly or easily. The 
controversies that have surrounded drug treatment 
stem as much from the sheer complexity of the 
drug problem— and the resulting potential for 
misconception and confusion— as from any other 
factor. The series of investigations and arguments 
that led to the committee's conclusions are 
logically retraced and presented in the chapters 
that follow. The report's organization is described 
briefly in the sections below. 



THE LOGIC OF THE REPORT 

Chapters 2, 3, and 4 set the stage for analyzing the 
clinical effectiveness and organizational features of 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



INTRODUCTION 



drug treatment coverage. Because it is critical to 
understand how drug treatment fits into and is 
shaped by drug policy as a whole, the committee 
undertook a general review of the historical and 
contemporary dimensions of drug policy, 
commissioning original analyses by Karst 
Besteman and committee member David 
Courtwright. Based on these and other sources, 
Chapter 2 assesses the role assigned to treatment in 
the ideas that govern drug policy, emphasizing the 
combination of medical and criminal conceptions 
of the problem that dominate current thinking. 

Chapter 3 focuses on epidemiological research 
knowledge and clinical experience regarding 
patterns of drug consumption behavior, the 
individual and social consequences of drug 
patterns, and the extent of the need for treatment. 
The special concerns of this chapter are drug abuse 
and dependence, recovery, and relapse—the 
behavior patterns that have the greatest 
significance for treatment programs. A special 
analysis of data from the Research Triangle 
Institute/National Institute on Drug Abuse 
(RTI/NIDA) 1988 National Household Survey and 
analysis of U.S. Bureau of Justice Statistics reports 
provide important reference points for this chapter. 



conditions and in the field. Chapter 5 thus surveys 
the available evidence on "what works" among the 
handful of conventional modalities of drug 
treatment. Discussing such aspects as how 
effective a treatment modality is, for whom, why 
or why not, at what cost, and with what level of 
benefits, the chapter draws heavily on analyses of 
the large-scale Treatment Outcome Prospective 
Study, a NIDA/RTI project. The chapter is 
equally concerned with what is not known about 
treatment modalities and results and leads finally 
to recommendations for improving the knowledge 
base about treatment. 

In analyzing the treatment literature, reviewing 
submitted evidence, and visiting treatment 
programs in the field, committee members were 
struck by differences between programs that 
principally served privately insured clients and 
programs that did not. These differences became 
dramatically evident in detailed analyses of data 
collected in the 1987 National Drug and Alcohol 
Treatment Utilization Survey (NDATUS). The 
differentiation of treatment providers into public 
and private tiers and the effects of this structure on 
treatment provision and accessibility in this 
country are discussed in Chapter 6. 



Given the policy contexts and the extent and 
character of the problems that require attention, 
what can treatment for drug problems be expected 
to achieve? Chapter 4 takes up the issue of 
defining a realistic set of treatment goals, 
particularly in terms of reducing illicit drug 
consumption and other criminal behavior. It notes 
the reluctance many individuals express about 
entering and complying with treatment, as well as 
the close association between the objectives of 
criminal justice agencies and drug treatment 
programs. This chapter draws on commissioned 
papers by Mary Dana Phillips and Gregory Falkin 
and colleagues. 

With the parameters of policy, epidemiology, and 
treatment objectives in place, it is possible to 
review efficiently the literature on clinical 
modalities of treatment and characterize the state 
of knowledge about their results under controlled 



Chapter 7 considers the public tier of treatment 
delivery, which is largely supported by federal, 
state, and local funds and in the main comprises 
nonprofit treatment programs that hold contracts 
with government agencies. To achieve the general 
goal of public coverage— ensuring that appropriate 
treatment is available to those who cannot afford it 
themselves— the committee offers a plan, complete 
with breakdowns of estimated costs, for three 
alternatives: a $2.2 billion comprehensive 
program, a $1 billion core program, and a $1.6 
billion intermediate program of expanded public 
support. The plan relies in the near term on direct 
program financing, with a longer term goal of 
incorporating drug treatment support more 
systematically into Medicaid and other mainstream 
health care payment mechanisms. Important 
components of the plan are more extensive 
outreach to mothers and criminal justice 
populations in need of treatment, well-developed 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 1 



systems of performance assessment, and better 
utilization review and control, particularly of high- 
cost elements. 

Private coverage for drug treatment is a result of 
decisions and negotiations by individuals, 
employers, insurers, care managers, and providers. 
Chapter 8 considers private coverage in terms of 
eligibility, benefit design, costs, and provisions for 
the management of care. Drug treatment is a 
relatively small but fast-growing element among 
private health insurance claims, and it is difficult 
to titrate precisely the factors that have led to this 
growth. Mandates for specific coverage have 
played some role but do not appear to be the most 
important factors at this time. The committee's 
major recommendation in this area is to broaden 
the scope of covered treatment while instituting 
better cost management and accountability. 
Commissioned papers by Richard Steinberg and by 
Paul Roman and Terry Blum were particularly 
useful in shaping the committee's analysis of 
private coverage. 

In reaching conclusions and formulating 
recommendations, the committee has relied 
wherever possible on rigorous evidence. On many 
issues, however, there is no such evidence by the 
usual standards of the scientific community. 
Consequently, the committee made judicious use of 
its best expert judgment in cases in which logic 
and experience pointed strongly but good evidence 
was scant. The grounds for this course lie in the 
complexity and severity of the nation's drug 
problem, the congressional charge to provide 
recommendations, and the public's underlying 
determination to respond. These conclusions are 
clearly signaled by explicit use of the formula, "in 
the committee's judgment." In virtually every 
such instance, the committee also specifies the new 
knowledge that needs to be generated to test and 
strengthen such judgments. 



ADDITIONAL POLICY QUESTIONS 

There are several issues bearing on drug treatment 
to which the committee members returned again 
and again during their deliberations but that they 



could not satisfactorily address because there was 
no clear basis from which to draw firm 
conclusions. In some cases, the issues involved 
large amounts of unanalyzed data and conceptual 
problems that extended beyond the sphere of 
treatment coverage. It was impossible to pursue in 
depth those matters that were centered far outside 
the study's mandate, however revealing the 
inquiries might eventually be. Nevertheless, the 
committee resolved to highlight here those issues 
it considered the most important: drug treatment 
specifically for adolescents and younger children, 
including drug-affected babies; the operations of 
the criminal justice system in relation to the drug 
consumer; and modification of the socioeconomic 
environment that conditions drug use, especially in 
impoverished neighborhoods. 



Treating Adolescents and Women with Children 

Most of the findings and recommendations in this 
report are based on and pertain directly to the 
treatment of adults, especially those aged 18 to 40 
years old. Juvenile drug problems rightfully 
capture a great deal of attention, but in terms of 
sheer demographic mass, the drug problems of 
major concern today occur principally in adult 
populations. The overwhelming majority of drug 
transactions are between adults, the social costs of 
their problems clearly predominate, and most 
identified drug treatment resources are directed 
toward them. Moreover, in comparison to 
juveniles, treatment research and evaluation data 
for adults are richer, the criteria for differential 
diagnoses are clearer, and typical adult treatment 
modalities are more sharply distinguished (for 
better or worse) from other mental and physical 
health care, education, criminal justice, and 
social/rehabilitative services. 

Unfortunately, much evidence suggests that 
juveniles who are directly or proximally involved 
in drug problems today are the source of 
tomorrow's pool of more severe adult drug 
problems. The committee consequently reviewed 
the scattered literature and discussed some of the 
problems encountered in treating adolescents, 
women with children, and drug-exposed infants. 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



INTRODUCTION 



However, no conclusions could be drawn from 
these investigations, although some substantive 
possibilities were derived and are discussed in the 
report. Of principal concern is the extent of the 
limitations of the knowledge base on whether 
treatment of the young has requirements different 
from those for treatment of adults. Also at issue 
are the changes in outcome that might be produced 
by variations in services. 

Considering the importance of treatment for 
juveniles and the paucity of necessary knowledge, 
the committee urges that drug treatment of the 
young— adolescents, drug-exposed infants, and the 
ages in between—be subjected to intensive study. 
Investigations must be designed to plumb the 
reservoir of practical clinical experience and 
research knowledge as deeply and systematically as 
possible to stimulate development of the kind of 
foundation and synthesis for policy purposes that 
is not yet at hand. The National Forum on the 
Future of Children and Families, a joint effort of 
the Institute of Medicine and the National Research 
Council, has recently conducted the first in a series 
of workshops and panel meetings to address some 
of these issues. 



The Criminal Justice System 

The criminal justice system at present is the first 
line of societal response to drugs, absorbing about 
90 percent of the public expenditures allocated to 
this problem. In fact, much of the nation's current 
drug treatment strategy and system was designed 
to allay public concern about street crime 
engendered and aggravated by drugs. This report 
examines the effectiveness of community-based 
treatment programs in terms of how well those 
concerns about drugs and crime are being satisfied. 
In addition, it presents conclusions about the 
legitimacy and effectiveness of correctional 
treatment and treatment of individuals on probation 
and parole and identifies ways in which treatment 
programs can and should relate to the criminal 
justice system. 



Beyond these issues, however, lie a range of 
critical questions about how the law enforcement 
and criminal justice systems are organized to deal 
with drug-related crime and how they distribute 
attention and resources to address its various 
manifestations— possession, trafficking, and other 
serious crimes. There is a crowded field of 
opinion and vested interest about these questions, 
as well as some relevant research. But there is no 
objective, comprehensive, up-to-date analysis of 
the criminal justice response to the drug problem, 
and the committee doubts whether any current 
efforts, including those of the Office of National 
Drug Control Policy, even aspire to develop one. 
This issue is a rapidly growing, multi-billion-dollar 
vacuum that demands to be filled. 



The Socioeconomic Environment 

It is difficult to overstate the critical importance of 
the socioeconomic environment. Individuals make 
choices, but they always do so in a social and 
economic environment, and there is ample 
evidence that such environments exercise great 
influence over drug consumption. They can 
promote the initiation of drug use, aggravate and 
amplify drug effects, and counteract the process of 
recovery from drug dependence. The capabilities 
necessary to change socioeconomic factors must be 
developed so that these environments will help 
channel more individuals away from rather than 
toward drug problems. 

The report covers some aspects of drug etiology 
and relapse that are relevant to environmental 
dimensions. Nevertheless, a comprehensive 
assessment of the extent and adequacy of 
preventive interventions in this domain was beyond 
the purview of this study. The committee looks 
toward investigations, such as the study of drug 
abuse prevention research now being conducted by 
the National Research Council, to address these 
issues and work toward comprehensive 
recommendations regarding appropriate 
environmental interventions to prevent drug 
problems. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



27 



CHAPTER 2: IDEAS GOVERNING DRUG POLICY 



Three fundamental ideas about drugs, the people 
who use them, and ways to respond to them lie 
behind drug treatment and virtually all other 
instruments of drug policy in the United States. 
Embodied in criminal, medical, and libertarian 
approaches, these governing ideas have dominated 
the terms of public discussion and the gross 
allocation of public and private funds. As a result, 
there can be no detailed analysis of drug treatment 
without first understanding what these ideas are, 
where they come from, how they relate to each 
other, and how they have shaped the role and 
functions of treatment. 

That the governing ideas are plural reflects two 
underlying realities concerning drugs and society. 
The first is that psychoactive drugs have a 
multiplicity of medical and social uses and 
consequences. Some of the uses are clearly 
beneficial, others are clearly pernicious, and still 
others are a complex mixture. Moreover, the 
pharmacopeia is not static but growing. New 
drugs and innovative technologies to administer 
them are constantly arising from scientific research 
and folk-pharmaceutical explorations. 

The second reality is the persistence of social 
change, including the dialectic of political parties 
and philosophies and the continuous renegotiation 
of relationships between different institutions of 
government. Such change ensures the potential for 
different ideas to gain or lose potency. Therefore, 
if the social arrangements supporting policies 
associated with one fundamental idea turn 
unfavorable, the programs arising from those 
policies may wither only to revive again if 
conditions change. 

The climate surrounding drug problems appears to 
be changing in the United States, but its future 
direction is uncertain. A complex balance of ideas 
and policies led to the current forms of drug 
treatment and treatment delivery. The major 
lesson of this chapter's analysis of historical ideas 
and their social roots is that a re-tuning of that 
policy balance appears to be in order. Such a re- 



tuning is, moreover, a prerequisite to ensuring that 
these programs— and perhaps other instruments of 
drug policy— will be able to function at the most 
humane and effective level possible. 



THE CHARACTER OF GOVERNING IDEAS 

In a democracy, government policy is inevitably 
guided by commonly shared simplifications. This is 
true because the political dialogue that authorizes 
and animates government policy can rarely support 
ideas that are very complex or entirely novel. There 
are too many people with diverse perceptions and 
interests and too little time and inclination to create 
a shared perception of a complex structure. 
Consequently , influential policy ideas are typically 
formulated at a quite general level and borrow 
heavily from commonly shared understanding and 
conventional opinions. (Moore and Gerstein, 
1981:6) 

Drug policy is no exception to the rule of simple 
ideas. For much of this century, drug policies 
were— and still are— profoundly affected by a body 
of conventional wisdom. Especially influential has 
been the belief that drug problems are largely 
attributable to morally compromised or 
pathological individuals who were not properly 
inculcated in childhood with normal American 
values such as self-control and respect for the law. 
These individuals must be disciplined and punished 
by authorities to deter them from involvement (for 
pleasure or profit) with inherently dangerous, 
addicting drugs. The power of ideas like these is 
apparent in that they are widely treated as obvious 
facts that any well-intentioned, intelligent 
participant in drug policy formation either 
subscribes to or treats very seriously. 

Much can be said for the wisdom of governance 
through shared ideas. If many people understand 
and agree with an idea, its prima facie legitimacy 
is established. Moreover, widespread 

understanding and acceptance of an idea 
establishes a necessary condition for effective 
policy implementation in any society in which 
governmental power is broadly dispersed. 



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IDEAS GOVERNING DRUG POLICY 



Although shared simplifications generally fail to 
reflect or capture all the important aspects of a 
problem, they at least focus attention on some of 
the more significant dimensions. Thus, simplified 
conceptions help to concert social attention and 
action— something that more complicated ideas 
usually cannot achieve. 

Yet there is also a price to be paid for simple 
ideas. Simplification inevitably distorts one's 
perception of a problem. Although some 
important features may be enhanced, others that 
could plausibly claim equal significance are 
subordinated. In turn, some avenues for social 
intervention may be brightly illuminated, whereas 
others that could well be as effective are obscured 
or condemned to obscurity. 

Such limiting approaches can be of two sorts. One 
simplifying strategy is to select a narrow set of 
effects or objectives. One could then focus on 
adverse health effects, for example, and promote 
policies that best reduced overdoses, withdrawal, 
and diseases such as AIDS that may be associated 
with drugs, taking everything else as of secondary 
importance. Alternatively, one might consider 
drug-induced crime to be of overriding importance 
and concentrate on policies that would effectively 
punish and isolate the drug user from society. 

A different simplifying approach is to decide 
which causes are most important in generating the 
adverse effects of drug use and then chose policy 
instruments that operate most directly on these 
causes. One might judge (on the basis of available 
evidence) that the total quantity of drugs used is 
the main determinant of the observed pattern of 
effects and try to develop policies that reduce 
overall drug consumption. Alternatively, one 
might determine that drug problems are mainly 
due to a relatively small number of unusually 
feckless or vulnerable users and tailor policies 
specifically to keep such people away from drugs 
(or treat or pretreat them in some fashion that 
would make them more problem resistant). 

The most successful simplifications combine both 
kinds of limitations: the major effect or objective 



of the policy and the judgment about what causes 
it are tied together into a neat conceptual bundle. 
A few such bundles have had widespread, durable 
appeal in U.S. society because they proved 
compatible with common social views, evolving 
social experience, and the interests and purposes of 
organized groups. These cognitive bundles are 
referred to here as governing ideas. Each has had 
considerable intellectual appeal and at some point 
succeeded in capturing the attention, imagination, 
and actions of the broad population. They provide 
the crucial context for understanding the nature of 
the drug treatment system, as well as the goals set 
for it and the financial arrangements that underlie 
it. 

THE SPECTRUM OF IDEAS ABOUT DRUGS 

The evolution of drug policy in the United States 
can be concisely and usefully described in terms of 
a simple spectrum or continuum of concepts that 
ranges from the least restrictive in approach to the 
most restrictive (Figure 2-1). Of course, reducing 
ideas to a one-dimensional continuum distorts them 
somewhat, stripping them of nuances and cross- 
fertilizations. Furthermore, the placement of ideas 
along this continuum does not necessarily refer to 
the actual consequences of policies but only to the 
character of the ideas that inform them. The 
determinants of policy consequences are more 
complex than ideas alone, embracing economic 
conditions, political mobilization, religious 
movements, and the educational level and degree 
of alienation or frustration of the population. 

Although the spectrum is continuous and shows 
that ideas shade into one another at their edges, 
simplification demands that sharper boundaries be 
drawn. Three main parts of the spectrum are thus 
distinguished, constituting the three major 
governing ideas that underlie the historical 
evolution of drug policy in the United States . As 
little as 100 years ago the left side of the spectrum 
was mainly in evidence. Only after the middle and 
right side had developed could drug policy be 
compared across the broad range of options. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 2 



Less 



restrictive j~ 
ideas 

r" 

© 
N 

» 

S 
1850 r 



LIBERTARIAN 



MEDICAL 



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CRIMINAL >*??, 
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CD 

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ideas 



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1890 



1909 



1923 



1965 



1990 



Government role limited 
to taxation 



Increase of municipal and state 
regulation: growing medical interest 
in addiction 



Criminal idea 
challenges medical 
approach as drug- 
taking population changes 



The classic era of 
narcotics control; 
increased minority 
involvement with 
drugs 



The rise of 
modem treatment 
modalities 




Major expanscn of 
the criminal justice 
system 



FIGURE 2-1 A simplified spectrum of governing ideas about drugs. The historical changes represented 
in this figure by a continuous trend line constitute the committee's summary judgments about the 
ideological "center of gravity" in the country from 1850 to 1990, based on the evidence reviewed by 
Courtwright and Besteman (both 1992) and elsewhere in the report, particularly Chapters 4 and 6. 



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IDEAS GOVERNING DRUG POLICY 



Libertarian Ideas 

Libertarian approaches to the drug problem are the 
oldest of the three sets of governing ideas. Until 
after the Civil War, imported drugs such as opium 
were relatively cheap and available without much 
restriction to those whose cultural customs, 
personal tastes, or medical needs motivated their 
use. This state of affairs was less a reflection of 
positive ideas about drugs than an outcome of the 
methods of governance in the new nation. 
American constitutionalism prescribed a weak, 
rather minimal federal government whose 
attentions had to be concentrated on a few matters 
where they could have an impact. The libertarian 
ideal is Jeffersonian at its heart, advocating 
minimal interference by government in private 
affairs or political expression. It envisions a 
relatively small government apparatus concerned 
for the most part on the national level with foreign 
affairs, national security, and the currency, and on 
the local level with protecting property rights and 
maintaining civil order. Libertarian ideas were, 
and still are, the default value in American 
political life; thus, minimal policy, expressed as a 
practical lack of interest in the actual or potential 
significance of drugs in society, was the reality for 
much of the nineteenth century. 

Only from the middle to the late 1800s, as the 
country's concern with the problem of alcohol was 
culminating in major legislative measures, did the 
libertarian approach (or nonapproach) to drugs 
begin to lose ground. This decline coincided with 
the growth of two other governing ideas: the 
criminal— that drug abuse is a problem of shiftless 
living closely associated with crime and violence— 
and the medical— that drug abuse is a medical 
problem arising from a misguided but 
understandable search for relief from painful or 
oppressive circumstances. 

Yet even before these newer ideas were 
articulated, libertarian thinking itself had begun to 
respond to shifts of several kinds that were stirring 
in the mid-nineteenth century. First among these 
currents of change were social and political 
developments. The abolition of slavery by the 



Union during and after the Civil War was a clear 
signal that the boundaries of political 
permissiveness were contracting. The spread of 
industrialization, the growth of American military 
(especially naval) power to world-class status, and 
the immigration of Asians and eastern and 
southern Europeans in unprecedented numbers 
from 1880 to 1920 remade the face of the country 
that the Jeffersonians had fashioned. In the end, 
the libertarian ideal of minimal government was 
shattered by the pressures of a growing and 
increasingly diverse population and especially by 
conflicts over the proper role of the national state— 
the federal government— in organizing economic 
life and aligning local political culture with a 
national vision. 

The libertarian view of drug use was further 
assaulted by a second, technological line of 
development. Modern chemistry and metallurgy 
isolated psychoactive botanical alkaloids such as 
morphine and cocaine and made their injection 
possible. The twentieth century saw the creation 
of exotic, mood-altering drugs, although these 
substances were not fundamentally different in 
effect from the nonsynthetics. Nevertheless, these 
new, more concentrated products altered the drug 
picture in numerous ways that included increasing 
the potential of drugs to induce addiction and a 
variety of unanticipated disease implications. (In 
the same way, the invention of shredded-leaf , flue- 
cured, machine-made tobacco cigarettes greatly 
changed the economic and epidemiological 
significance of tobacco products.) 

The third development was the increasing concern 
about a new type of drug user: the "pleasure 
user," for whom drugs were neither bound to 
tradition or custom nor a source of relief from 
physical pain. Although the pleasure user was 
sometimes stereotyped in racial terms— associated 
originally with Chinese immigrants, later with 
African and Mexican Americans— the model was 
just as often the European American urban 
criminal, a member of the underworld linked to 
prostitution, thievery, and saloon-going. 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 2 



The libertarian indifference to drugs was 
challenged by these developments and began to 
give way before pressure for some kind of 
governmental action. Early legislation tried to 
discourage opium smoking by outlawing opium 
dens or levying high taxes on imports of opium 
prepared for smoking. In 1906 the federal 
government passed legislation that required 
nostrum makers to list all ingredients, including 
narcotics, on the label. A number of states also 
passed laws requiring that narcotics be sold only 
by prescription and that pharmacists record all 
transactions. Ultimately, the U.S. Congress 
passed legislation to ban imports of opium 
prepared for smoking and attempted to confine 
other narcotics transactions entirely to medical 
channels. 

Today, there are still some adherents to libertarian 
views regarding the problem of drugs, particularly 
in regulatory approaches, and these ideas have 
experienced something of a renaissance in the past 
several years. Yet the actual policy contributions 
of this idea are now largely constraining rather 
than leading. For example, libertarian ideas have 
limited the spread and influenced the character of 
employee drug testing (see Roman and Blum, 
1992). On only one issue, the reduction of 
statutory penalties from the felony level to 
misdemeanors or infractions for the possession or 
transfer of small amounts of marijuana, has the 
libertarian idea attained a semblance of governing 
force in recent years—an effect that reached its 
current perimeter of authority in 1973 with the last 
of 11 state decriminalizations. 

On a more abstract level, the decision-making 
logic characteristic of libertarian thought—namely, 
its calculus of utility— has retained some influence. 
In this theory of action, an individual, operating 
within the bounds of law and civility 
(noninfringement of others' fundamental rights), 
makes those expenditures— which may include the 
purchase of treatment— that in the individual's view 
will provide benefits that most exceed the cost of 
purchase. On an aggregate level, the polity, in its 
collective decisions, should at the least permit (if 
not encourage outright or, under appropriate 



circumstances, spend collective funds for) the 
supply of those goods or services whose aggregate 
benefits most exceed their costs. This logic 
implies an economic cost/benefit standard by 
which to measure the worth of public or private 
purchases of drug treatment. It has been used in 
some analyses, although it has not played a 
primary role in treatment policy. 



Medical and Criminal Ideas 

The medical idea arose in the 1870s and 1880s as 
physicians began to realize that a significant 
number of citizens, mostly middle-class, 
"respectable" women, were addicted to powdered 
morphine sulphate and other opiates. (The number 
was later estimated at several hundred thousand, 
but lower figures were actually more realistic 
[Courtwright, 1982, 1992].) Many of these 
individuals began to use these drugs on the advice 
of physicians to deal with a physical problem or a 
"nervous" complaint. There was widespread 
medical prescription, promotion, and sale of 
opiates and other substances for a variety of 
ailments and as routine "tonics." It gradually 
became clear to observant practitioners that 
individuals who had become accustomed to using 
these compounds became ill, agitated, and 
despondent if they tried to do without them; yet 
these same individuals functioned reasonably well 
with continued regular doses, even though these 
doses often reached high levels. 

Opiates were very much a staple of nineteenth- 
century medical practice— one of the few truly 
effective medicines of the day, capable of reducing 
the suffering of many patients for whom no other 
useful medical intervention was known. As a 
result, this observation of the addictive effects of 
chronic use was viewed as regrettable but not 
catastrophic, particularly because so many of those 
affected were older women, many of whom had 
begun using the habit-forming drugs under medical 
or pharmaceutical advice or supervision and who 
on the whole seemed harmless. One standard 
medical response to this problem was maintenance 
on a prescribed dose, with the goal of continuing 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



IDEAS GOVERNING DRUG POLICY 



the patient on a course of normal, comfortable 
functioning. A variety of detoxification therapies, 
some sensible and some quite exotic, were also 
attempted, but relapse to habitual use was 
common, making maintenance appear even more 
reasonable as an alternative. 

Of much greater concern were "opium habitues" of 
the lower social classes whose lives centered 
around multiple, daily periods of intoxication 
achieved through the opium pipe, the needle, or 
tinctures of high opiate (and alcohol) content. 
These individuals were quite different from 
respectable middle-class users— but their agitated 
responses to a threatened loss of access to the drug 
were quite similar. From these observations, 
physicians formulated the medical view of narcotic 
drugs: whatever the origins of opiate use or the 
prevailing moral judgment regarding it, individuals 
invariably display an addiction withdrawal 
syndrome if they have consumed powerful 
intoxicants such as narcotics for a long enough 
period. This syndrome involves physical distress 
when the drug is withdrawn, which is relieved 
when it is taken, and craving for the drug when 
the individual is abstinent. The similarity between 
the alcohol and narcotic addiction and withdrawal 
syndromes was recognized in many quarters. 

The initial explanation developed for these 
phenomena was an extension of psychiatric theory 
of the period. The middle-class people who 
sought opiates seemed to belong to the 
"neurasthenic" personality type— people of 
weakened and unstable temperament who needed 
pharmacological assistance to endure the rigors of 
modern life. In the 1920s, as physicians saw more 
and more urban "pleasure users," a darker 
assessment arose: these users seemed more and 
more to be afflicted not with temperamental 
weakness but with psychopathic dispositions. 

This darker medical assessment of the drug 
problem began to resemble the view taking shape 
as modern "scientific" police forces were 
organized in the rapidly growing cities of the late 
nineteenth and early twentieth centuries. 
Formulators of a view of drug use as a criminal 



matter were more impressed with the criminal 
associations and irresponsibility of disreputable 
drug users than with the commonalities in 
symptomatology with respectable users. The 
criminal view held that narcotic drug use was 
fundamentally immoral, ruinous behavior. The 
lower class user was seen not only as self- 
destructive but as someone who might encourage 
and lure others into drug use and who could be 
emboldened by drugs to commit more and graver 
crimes. 

In the criminal view of the drug problem, families, 
with churches and schools as social backstops, are 
fundamentally responsible for teaching children to 
behave responsibly and morally, behavior that 
includes shunning intoxicating drugs. The 
presence of moral anchors— most generally, the 
capacity for self-control in the face of temptation 
and a generalized respect for the law—is the vital 
element that separates the good citizen from the 
pleasure-seeking drug user. If the family or 
school, for whatever reason, fails in its 
responsibility to provide moral education, the 
problem must be dealt with by another authority. 
The main such agencies are the police, the courts, 
and prisons; there may, however, be room for 
intermediate socializing agencies (guidance 
counseling or social work) to supplement or 
substitute for the family, especially in cooperation 
with the juvenile justice system. 

The criminal and medical views of the U.S. drug 
problem during the late nineteenth and early 
twentieth centuries had two rather different 
perceptions of drug users. The medical observers 
who originally developed the idea of addiction 
viewed the user population largely as members of 
the middle class and majority ethnic groups who 
were unfortunates worthy of help. But 
increasingly, from 1895 to 1920, the medical 
profession, the police, lawmakers, and the public 
in general saw the ranks of users as predominantly 
lower class in income and occupation and often of 
minority ethnic composition (that is, minorities not 
originating in northern and western Europe). The 
association of pleasure drug use with poor 
Chinese, Italians, slavic Jews, Mexicans, and 



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SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1, CHAPTER 2 



African Americans deepened the rift of censure 
that divided official community moral guardians 
from drug users; the compassionate impulse to 
comfort the wretched became more and more a 
determination to administer a good swift kick to 
the wayward. 



The Classic Era of Narcotics Control 

The mixture of the two competing views, medical 
and criminal, was an uneasy one. The Harrison 
Act of 1914, aimed at controlling the distribution 
of narcotics, skirted the question of indefinite drug 
prescription for an addict's personal use. In 1919, 
however, a critical court case, decided by a 
Supreme Court vote of 5 to 4, firmly established 
the legal basis for prosecuting addicts and 
physicians who maintained them. Once this bridge 
was crossed, the criminal view quickly gained 
ascendancy in the debates surrounding drug policy 
formulation. 

The medical view, on the other hand, was set back 
dramatically during the prohibitionist and 
xenophobic 1920s, as many physicians who 
prescribed opiates to addicts were visited by 
federal agents, and several efforts to treat addicts 
in morphine or heroin maintenance clinics were 
abruptly terminated. Addicts were sought, 
prosecuted, and jailed in unprecedented numbers— 
so many were imprisoned, in fact, that they 
strained the capacities of the federal prison system. 
In response to this overcrowding, federal prison 
wardens made a pact with advocates of the medical 
approach (represented by the U.S. Public Health 
Service), and the U.S. Congress agreed to fund 
two massive new "farms" for narcotics addicts- 
federal prison-hospitals that would accept both 
inmates and voluntarily committed patients. These 
facilities were opened near Lexington, Kentucky, 
and Fort Worth, Texas, in 1935 and 1938. 

The criminal view dominated the nation's drug 
control efforts for more than 40 years, during most 
of which Federal Narcotics Bureau Director Harry 
Anslinger was the leading figure of narcotics 
policy and dealers and nonmedical users were 



arrested at virtually every opportunity. 
Nevertheless, the criminal view of drug problems 
was affected by changing times and changing ideas 
about controlling criminal behavior. Within this 
fundamental view of drug use as a criminal 
problem and users as moral derelicts deserving of 
retribution, several variants have arisen that 
correspond to philosophies reflected in the broad 
streams of modern criminological thought. The 
idea of rehabilitation-- criminals may be redeemed 
by appropriate arrangements, incentives, and 
lessons fashioned within the penal environment— is 
the basis of prison as a place of penitence, or 
"penitentiary"; it is explicit as well in the term 
"corrections." Evidence of its diffusion is also 
found in widespread acceptance of probation—a 
period of testing to discover the true character of 
the offender— as an appropriate response to first or 
minor offenses. The concept of deterrence draws 
a sharper line: the lesson conveyed by punishment 
is intended not only for the individual but also for 
the community as a whole, or at least for all others 
who might consider similar deeds. Finally, 
incapacitation takes the bleakest view of the 
criminal, putting little stock in the possibility of 
redeeming or deterring criminal behavior. Instead, 
this school of thought calls for protecting society 
by isolating the criminally inclined for the longest 
period consistent with community standards of 
"just deserts" for the crime, or crimes, committed 
(in the extreme, a sentence of life-or death). 



THE RISE OF MODERN TREATMENT 



The nation's drug problem seemed to diminish 
slowly but steadily during the Depression and 
World War II. The number of underworld addicts 
did not change much during this period, but as the 
cohort of more "respectable" medical addicts aged 
and died, they were not replaced. By the turn of 
the century, the health professions had become 
more sophisticated and scientific regarding the use 
of narcotic medications, cautions about patent 
medicines had increased, and nonnarcotic 
analgesics such as aspirin had come into 
widespread use. As effective medical therapies 



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IDEAS GOVERNING DRUG POLICY 



multiplied, the use of narcotics for the 
symptomatic treatment of pain in a wide range of 
illnesses declined. 

Around 1948, however, active heroin markets 
began to resurface in American cities. A wave of 
"drug epidemics" began, which continued into the 
1950s and early 1960s despite increasing criminal 
penalties. Dismayed by the escalation of 
seemingly fruitless criminal sanctions, a series of 
blue-ribbon government and private panels began 
urging a reconsideration of the national 
commitment to a nearly exclusive criminal 
approach. 

The beginnings of the national treatment effort lay 
within the federal prison-hospitals at Lexington, 
Kentucky, and Fort Worth, Texas. These facilities 
not only incarcerated criminals on narcotics 
convictions but also provided therapeutic services 
for their drug addiction. In addition, the two 
facilities served as sites for fundamental research 
on the course of drug dependence, the behavioral 
and physiological processes related to drug use, 
and the properties of narcotics. The benefits of 
the programs, however, proved elusive: 
evaluations indicated that the detoxification and 
unstructured psychotherapy delivered at these 
hospitals probably had limited if any long-term 
effectiveness (e.g., Hunt and Odoroff, 1962; 
Vaillant, 1966). 

Still, the federal hospitals were pivotal in three 
respects in the evolution of the community-based 
treatment system. First, the narcotics "farms" 
preserved the pre-control-era right of access that 
enabled addicts to commit or admit themselves 
voluntarily to treatment for addiction without being 
convicted of a criminal act. Second, the prison- 
hospitals established the precedent of direct federal 
provision of specialized treatment. Finally, 
through Public Health Service research programs 
and psychiatric residencies, Lexington and Fort 
Worth exposed a cadre of researchers and 
psychiatric clinicians to the challenges of treating 
drug-dependent individuals. When the new 
community-based treatment modalities of 
therapeutic communities and methadone 



maintenance were introduced and disseminated, 
this group of clinicians and researchers, whose 
careers had dispersed them across the country, 
were of critical importance in implementing and 
evaluating the new programs and organizing 
training initiatives. 



Methadone Maintenance, 

Therapeutic Communities, 

and Outpatient Nonmethadone Programs 



Methadone maintenance, a treatment modality first 
formally described in the Journal of the American 
Medical Association, (Dole and Nyswander, 1965), 
was originally based on an explicitly medical 
concept that substantial heroin use created a 
persistent if not permanent imbalance of brain 
metabolism, which could be stabilized by the right 
pharmacological treatment. This notion was a 
more sophisticated version of the physiological 
ideas current among some of the physicians who, 
for a short period after 1919, operated medical 
maintenance clinics using morphine in a number 
of American cities— until federal agents shut them 
all down by 1923. Federal agents also wanted to 
stop methadone maintenance at its inception but 
backed down from openly challenging its 
determined originators in court. 

Vincent Dole and Marie Nyswander, a 
distinguished research endocrinologist and a 
Lexington-trained psychiatrist, respectively, 
discovered during hospital studies of the effects of 
different opiates that giving heroin addicts an 
appropriately adjusted, daily oral dose of a 
relatively long-acting, synthetic opiate called 
methadone led to quite different effects than those 
resulting from other opiates. (Methadone was 
invented by German chemists as a morphine 
substitute during World War II; its addiction 
liability and acute effects had been further studied 
at Lexington.) Heroin addicts who were 
maintained on oral methadone experienced neither 
euphoria nor withdrawal, rarely displayed any 
toxicological side effects, and thus were able, if so 
motivated, to begin or resume more conventional 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 2 



lives—and with Dole and Nyswander's therapeutic 
assistance, most of the early patients were so 
motivated. 

Dole and Nyswander were mainly concerned with 
individual patients who could now forego their 
obsession with acquiring drugs, an obsession that 
had led many of them to crime. But they and 
others saw broader implications to their work for 
the entire community, which might be spared 
thousands of criminal acts, once such obsessions 
ended. Thus, as the Kennedy -Johnson era "War 
on Poverty" gave way to the Nixon era "War on 
Crime," a rapid expansion of the methadone 
treatment program begun by the city of New York 
in the wake of the Dole/Nyswander research was 
underwritten by the federal government and 
implemented nationally. The goal of the expanded 
treatment was to take crime-committing addicts off 
the streets and out of the jails, on the theory, 
buttressed by substantial amounts of evidence, that 
a large proportion of these addicts' crimes were 
committed to support their addiction. 

The Dole-Nyswander model soon evolved to a 
different stage as a result of regulatory conditions 
imposed by the Food and Drug Administration at 
the behest of the Bureau of Narcotics and 
Dangerous Drugs. These regulations, which were 
"interpreted" still further by the state inspectors 
who enforced them, reflected major concerns about 
the diversion of methadone from closely 
supervised pharmaceutical administration to street 
drug markets. Although these concerns were well 
grounded in evidence, the possibility of such 
diversion was viewed with little alarm by some 
clinicians who considered diverted, street- 
purchased methadone a less dangerous substance 
than injectable heroin and who saw the street 
methadone market as a potential step toward clinic 
admission. The regulations also incorporated 
biases against indefinite maintenance, toward low 
dose levels (of arguable efficacy), and toward 
certain therapeutic rigidities, including specific 
staffing and facility parameters. 

A completely different treatment approach 
originated in California with Synanon, the original 



therapeutic community for drug addiction. Charles 
Dederich, founder of Synanon, drew some of its 
central treatment concepts from psychiatric 
therapeutic community in military medicine (Jones, 
1953) and from the fellowship of Alcoholics 
Anonymous. But the therapeutic community was 
most clearly compatible with the psychological 
rehabilitation concepts of the criminal view of the 
drug problem— except that it was devoted to 
building a self-policing community as a path 
toward redeeming addicts. In a move symbolic of 
this linkage with criminal justice concepts, an 
important second-generation therapeutic 
community, Daytop Village, was founded directly 
under the auspices of the Brooklyn probation 
department with a community-based board of 
trustees (Joseph, 1988), and therapeutic 
communities were soon implemented in numerous 
prisons, including the Fort Worth facility 
(Maddux, 1988). Over time, the more rigidly 
punitive dimensions of the early therapeutic 
communities were softened as clinical experience 
became more sophisticated and additional 
professional components were integrated into the 
concept. Nevertheless, the therapeutic community 
remains a remarkable merger of the therapeutic 
optimism of psychiatric medicine and the 
disciplinary moralism of the criminal perspective. 

The third locus of expansion of the treatment 
network in the early and mid-1970s, and the 
backbone of treatment efforts in most of the 
country today, was outpatient nonmethadone 
treatment. Comprising various forms of 

counseling, psychotherapy, and supervision, this 
branch of the treatment network developed 
originally in the 1960s in the matrix of federally 
supported community rehabilitation and community 
mental health services. Outpatient nonmethadone 
programs were the most diversified of the 
treatment approaches, both institutionally and 
therapeutically. 

The Narcotic Addiction Rehabilitation Act 
(NARA) of 1966 was the first major federal 
acknowledgment of the reemergence of the medical 
perspective. Building on the examples of earlier 
California and New York civil commitment 



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IDEAS GOVERNING DRUG POLICY 



initiatives, NARA took the significant step of 
authorizing community-based supervision and 
treatment of addicts after release from 
incarceration (on parole) . The authority of NARA 
was used to provide grants-in-aid and contracts to 
community programs delivering treatment and 
supervision. By 1970, roughly 150 local NARA 
programs were in operation (Besteman, 1992). 

The next breakthrough for the application of 
medical ideas came with a 1968 amendment to the 
Community Mental Health Centers Act. This law 
mandated and supported the provision of treatment 
for drug abuse and alcoholism within community 
mental health centers, a major health policy 
initiative that originated during the Kennedy 
administration. 

At roughly the same time as the 1968 amendment, 
the Office of Economic Opportunity (OEO) began 
to support community-based drug and alcohol 
treatment programs, particularly those that offered 
a variety of treatment alternatives. A model 
program in this respect was the Illinois Drug 
Abuse Program in Chicago, which pioneered the 
"multimodality" approach. It was characterized by 
a central point of program entry to assess the 
patient's needs and living situation, followed by 
assignment to whichever of several modalities 
within the program seemed appropriate. In 
addition, each patient received an individualized 
treatment plan that called for gradually decreasing 
program services as rehabilitative milestones were 
achieved. The director of the Illinois program, 
Jerome Jaffe (a psychiatrist and alumnus of 
Lexington), later became the first head of the 
White House Special Action Office for Drug 
Abuse Prevention— the first national "drug czar." 

Chemical Dependency Treatment 

The final significant phase of the application of the 
medical idea to drug use since the mid-1970s has 
occurred largely outside the public system of drug 
treatment. The 1980s have seen the rapid 
expansion of a privately financed network of 
programs providing chemical dependency 
treatment, a derivation of ideas associated with a 



neighboring but generally autonomous domain: 
the treatment of alcoholism using the 12-step 
recovery concepts of Alcoholics Anonymous but 
operating under the umbrella of the health 
professions. The idea of bringing recovered 
alcoholics into the hospital setting as part of a 
therapeutic alliance was developed at Willmar 
State Hospital in Minnesota; it was further 
extended and refined (to include, for example, 
family therapy where indicated and a two-year 
^ambulatory aftercare phase) at the Hazelden 
Foundation and the Johnson Institute, nonprofit 
treatment agencies in that state. In consequence, 
this modality is often called the "Minnesota 
model," and units implementing the modality are 
often called "28-day programs," based on a figure 
for an average length of inpatient stay reported at 
one time by the Hazelden center. 

Although its origins were in the public sector, the 
chemical dependency modality is now most widely 
provided by private for-profit and not-for-profit 
hospitals and rehabilitation facilities that draw most 
of their revenues from third-party insurance 
payments. The typical client in this system is not 
the convicted criminal or sometime blue-collar 
worker generally found in the public system, 
whose drug use frequently involves a combination 
of heroin, cocaine, and amphetamines along with 
heavy alcohol consumption. Instead, the typical 
client here is steadily employed, often a white- 
collar professional, who is abusing or dependent 
on cocaine and alcohol. Alternatively, he or she 
may be a marijuana-dependent middle-class 
teenager who is failing school and is finally sent to 
treatment by worried parents. A third staple client 
is the counterpart of the middle-class neurasthenic 
of days gone by—an older, female, nonworking 
user of depressants, including barbiturates, 
tranquilizers, and alcohol. 



The Medical/Criminal Idea of Treatment 
and the Evolution of Governmental Roles 

The most important single federal treatment 
initiative since the founding of the Lexington and 
Fort Worth facilities was the "War on Drugs" of 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



37 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 2 



the Nixon administration. This effort directly 
enlisted community-based drug treatment in the 
task of decreasing criminal activity on the streets 
of the nation's big cities. The concept of 
treatment as visualized in the national strategy 
merged the criminal and medical ideas in a single 
framework. It drew on the popular impression 
that heroin addiction, because of its great expense, 
motivated addicts to take up criminal careers. 
Police estimated that half of all major urban crimes 
were committed by addicts. If the new forms of 
treatment were successful in eliminating the desire 
or need for heroin, the criminal chain would be 
broken; if enough addicts were treated, national 
crime rates would be dramatically reduced. 

President Nixon, who had already made the war 
on street crime a centerpiece of his domestic 
policy, became convinced that attacking the drug 
problem would be the key to winning that war. 
By massively increasing the number of both 
correctional and community-based treatment 
program "slots" available to criminal addicts, it 
was felt that increased street-level police activity 
(supported by a new federal Law Enforcement 
Assistance Administration and Office of Drug 
Abuse Law Enforcement) could not only 
incapacitate but also rehabilitate. Through an 
Executive Order in 1971 and subsequent 
legislation, the Special Action Office for Drug 
Abuse Prevention (SAODAP) was created in the 
Executive Office of the President; it was given an 
unusually broad mandate and the authority to 
organize, direct, and evaluate the federally 
supported drug treatment effort. 

The high point of federal commitment to drug 
treatment occurred when the Special Action Office 
negotiated directly with local treatment providers 
to "buy" their waiting lists (i.e., provide sufficient 
new funding to admit these individuals for 
treatment). The Special Action Office also 
required that preexisting levels of local funding be 
maintained and specified the nature of treatment to 
be delivered. Moreover, it set reimbursement 
rates prospectively on the basis of those 
specifications, monitored treatment program 
performance in terms of both enrollment and 



patient status at discharge, provided technical 
assistance to program managers, and organized and 
delivered staff training. 

Although this initiative marked the fullest 
commitment of the federal government to building 
a national drug treatment system, it also laid the 
groundwork for its dismemberment and subsequent 
parceling out to the states. Under this initiative, 
the first grant program was established to deliver 
funding to states instead of directly to communities 
or providers. For the first time, states were 
required to designate a lead agency and develop 
and submit to the federal government their own 
plan for establishing and operating a treatment 
system. Furthermore, the contracts being made 
with community treatment agencies at this time had 
explicit provisions for progressive cost sharing, 
with the federal contribution to be reduced over 
the life of the contract. The program or 
community was required to make up the declining 
federal share from state or local appropriations or 
other sources (including client fees). 

In 1973 the narcotic drug abuse branch of the 
National Institute of Mental Health was separated 
and elevated to become the National Institute on 
Drug Abuse (NIDA), collecting from across a 
number of government departments all of the 
major treatment and prevention services and drug 
abuse research programs. Although an Office of 
Drug Abuse Policy continued to exist in the White 
House, NIDA assumed SAODAP's responsibility 
for the national treatment system; Robert DuPont, 
the head of SAODAP following Jerome Jaffe's 
departure, became NIDA's first director. 
Responsibility and authority were given to state 
agencies progressively, leading to the institution of 
relatively unfettered block grants to the states in 
1981 for allocation among alcohol, drug, and 
mental health programs. Since 1981 the federal 
share of payment for drug treatment programs has 
dropped well below the state share, and federal 
activities in the treatment field, particularly the 
mission of NIDA, have concentrated on biomedical 
and, to a lesser degree, behavioral and social 
sciences research. 



38 



NIDA DRUG ABUSE SERV/CES RESEARCH SERIES, No. 2 



IDEAS GOVERNING DRUG POLICY 



More broadly, drug policy at the federal level has 
shifted its focus to direct an increasingly greater 
proportion of attention and resources toward 
enforcement and interdiction. This emphasis was 
apparent throughout the Reagan administration and 
in the provisions of the 1986 Anti-Drug Abuse 
Act. Passed in the wake of the deaths of several 
prominent athletes from cocaine overdose, this bill 
symbolized heightened public and governmental 
concern about the drug problem, particularly 
cocaine, and translated that symbolism into large 
sums of federal dollars—far more of which were 
assigned to enforcement and prevention services 
than to treatment. 

The 1988 Anti-Drug Abuse Act and 1989 
emergency supplemental appropriation for 
treatment and prevention signaled a reconsideration 
of the balance of federal attention, driven by 
concern about the startling increase in gunshot 
deaths in crack-selling areas in and around 
Washington, New York, and Los Angeles, and by 
the steep incidence of AIDS connected with drug 
use in these and other areas. Along with 
continued large sums for enforcement, the 1988 
act authorized significantly increased funding 
commitments to the alcohol/drug/mental health 
block grant, together with higher "set-asides" 
(funds specifically earmarked) for drug treatment. 
The act also initiated a new temporary program 
specifically to reduce treatment waiting lists 
through grants to providers (reminiscent of the 
approach of SAODAP). However, as a 
consequence of Congress's deficit-driven spending 
limits, not much of the authorized increase was 
appropriated. 

The 1988 act also created a new Office of National 
Drug Control Policy in the White House. The 
office is directed by a quasi-Cabinet-level "drug 
czar," who is assisted by respective deputies for 
supply and demand reduction; it has unusual 
budget control authority, high visibility, and a 
statutory requirement to develop an annual 
National Drug Control Strategy. The first director 
was appointed in 1989: William Bennett, a lawyer 
and trained philosopher who previously headed the 
U.S. Department of Education. 



The new office is a chrysalis of the ideological 
elements of national drug policy. The first 
national strategy document (issued in September 
1989) sweepingly rejected libertarian ideas and 
argued for much tougher criminal approaches to 
drug users. Medical ideas were drawn upon in 
two contexts: the public health argument that the 
casual or regular (nonaddict) user is "highly 
contagious ... a potential agent of infection" and 
that drug addiction is a chronic disease with no 
permanent cure, thus presenting the continuing 
possibility of relapse. The document defined 
treatment's role in terms of the medical/criminal 
idea, leavened with additional concerns 
characteristic of America in the 1980s, such as 
danger to the lives of unborn children, AIDS, and 
the economy. In line with the overall stress on a 
stronger criminal view, the document argued for a 
reexamination of the effectiveness of voluntary 
(versus enforced) drug treatment. The second 
document, which was released in January 1990, 
was more sophisticated in its analysis of the 
treatment system, but it continued the major 
strategic emphases of the initial edition. 



CONCLUSION 



It would be natural to assume that drug treatment 
is the kept creature of medical approaches to the 
drug problem, that treatment programs are 
compatible only with medical ideas and must stand 
in a relationship of contradiction or antagonism to 
both libertarian and criminal ideas and institutions. 
Nevertheless, both in principle and in practice, 
drug treatment is a flexible set of instruments 
capable of achieving several socially desirable 
objectives and of serving more than one 
ideological master without necessarily losing its 
essential rehabilitative character. Because of the 
complex and constantly changing character of the 
drug problem, practical policies to deal with it will 
always need to meld the fundamental ideas in some 
way; as a result, policy differences over treatment 
are more often matters of emphasis, priority, and 
allocation than of rigid ideological exclusion. 
Each major governing idea is influential in 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



39 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 2 



determining the policy role of treatment and what 
it should be expected to contribute. 

In the case of each idea, the implicit standard of 
treatment success looks to serve both the individual 
and the collective interest. Libertarian ideas argue 
that, for the individual, treatment should maintain 
or increase the individual's privacy and 
independence, which may have been diminished by 
drugs; for the society, treatment should reduce net 
social costs (such as public medical and criminal 
justice expenses) and increase productivity (job 
earnings and tax receipts). Medical ideas also 
imply two standards: for the individual, response 
to therapy is measured in terms of reduced 
morbidity and mortality, that is, relief of suffering 
from somatic illnesses and psychological 
distortions and compulsions, and greater longevity. 
For the society, the public health should benefit 
through an overall reduction in the prevalence of 
drug morbidity and mortality, which have a 
disproportionate effect among the young, and 
perhaps through reductions in incidence or further 
transmission to the degree that drug problems are 
communicable from the treatable population. 

The criminal view focuses on the reduction of 
illegal conduct—not only drug offenses per se but 
also associated personal, property, and public- 
order crimes. The collective counterpart to 
individual treatment effects would be a reduction 
in overall rates of criminal victimizations, 
prosecutions, and incarcerations. 

Libertarian, criminal, and medical goals overlap in 
practice. For example, the calculus of social 
benefit and cost includes the costs of illness and 
criminality. The therapeutic objectives of drug 
treatment include social adjustment and satisfaction 
(including reduced criminal involvement); in the 
prevention-oriented disciplines of mental health 
and public health, the damaging effects of 
individual behavior on others through criminal 
activity are important concerns. Finally, the 
missions of probation, corrections, and parole 
authorities with regard to their supervisees often 
extend beyond the prevention of criminal behavior 



to imparting legitimate job skills and improving the 
fulfillment of family and community obligations. 

The treatment system that was built under federal 
direction in the early 1970s and that continues 
today is based on a balance of ideological 
concerns. The national policies of the early 1970s 
concentrated criminal justice efforts on the drug 
judged most dangerous—heroin— while expanding 
the options for treatment programs that could work 
cooperatively with criminal justice institutions. 
Since 1975 the balance of public policy has moved 
steadily back toward the criminal idea, while the 
momentum of the medical idea has shifted into the 
private realm and led to increasing treatment of a 
segment of drug problems in private hospitals and 
clinics. The movement on the public side has been 
heavily responsive to larger political currents that 
have favored security interests over other welfare 
concerns. There continue to be strongly expressed 
as well as inchoate sentiments favoring libertarian 
approaches, but the net movement has been a 
massive transfer of public emphasis to enforcement 
and incarceration at the expense of the public 
treatment sector. That pendulum appears to have 
swung to its limit, and the opportunity for explicit 
reconsideration of the role, extent, and financing 
of public and private drug treatment is greater now 
than at any point since the mid-1970s. This is the 
context in which the following chapters describe 
the problems that treatment can address, examine 
where and how the treatment supply system has 
changed, present plans to restructure it where 
needed, and define the costs and benefits that may 
accrue. 



40 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



CHAPTER 3: THE NEED FOR TREA TMENT 



The history of drug policy provides evidence on 
the role of treatment programs in the array of 
policy responses to the drug problem. But what 
exactly needs to be treated? And how widespread 
is it? These questions are addressed in this 
chapter, which specifies the current need for 
treatment in terms of objective criteria based on 
scientific research and clinical experience. This is 
not the same as determining who wants treatment. 
Subjective motives or desires to seek help are not 
necessarily consistent with objective evaluation or 
practicality. Assessing need is also different from 
measuring the actual demand for treatment, which 
is critically bound up with treatment cost and the 
ability and willingness of someone— the individual, 
a charitable provider, a third party, or some 
combination of these—to cover that cost. The 
issues of wants/motives and demand/cost are 
covered in subsequent chapters; the focus here is 
on scientific and clinical understanding of the drug 
problem, which enables a definition and 
measurement of treatment needs. 

In clinical applications, diagnostic criteria can be 
used to determine, within an accepted range of 
precision and replicability, whether treatment is 
needed in an individual case. By appropriate 
methodological extension, these criteria can 
provide a probabilistic estimate of the aggregate 
need for treatment in the population as a whole. 
Refined diagnostic tools, in combination with 
treatment effectiveness studies, might further 
indicate not only whether treatment is needed but 
also what type is most likely to be beneficial. 

Diagnostic criteria, which are discussed in detail 
below, distinguish drug use— for which no 
treatment is called for, although other responses 
may be— from drug abuse and dependence. The 
criteria are based on the level and pattern of drug 
consumption and the severity and persistence of 
functional problems resulting from these 
consumption patterns. Their development has 
been an evolutionary process, and consensus is not 
yet total. Reasons for this gradual rate of progress 
are not hard to locate. Drug consumption patterns 



and their consequences are extremely complicated 
and continually changing. The modalities and 
philosophies of treatment are diverse. And as new 
drugs and ways of administering them appear, the 
applicability of even well-tested diagnostic criteria 
must be reestablished. 

As a basis for understanding the need for 
treatment, the committee first outlines a conceptual 
model of the different types and stages of 
individual drug consumption and its consequences: 
use, abuse, dependence, recovery, and relapse. 
The major factors that are thought to propel this 
model are then summarized, namely, individual 
learning processes that lead to the modification, 
persistence, or extinction of drug consumption. 
Learning is contingent on drug effects, socially 
conditioned reinforcers, and, to some degree, 
personal characteristics. In turn, the availability of 
drugs and other reinforcers and of good 
opportunities for character development are 
strongly shaped by economic, political, and 
cultural factors that vary through time and across 
different geographic locations. 

Treatment focuses largely on ending or at least 
reducing the severity of an individual's dependence 
or abuse and associated problems— that is, on 
initiating and maintaining recovery and averting 
relapse. In the sections that follow, the committee 
analyzes a number of general and special- 
population surveys that include items 
approximating the diagnostic criteria for 
dependence and abuse. These analyses yield new 
estimates of the need for treatment in the 
population at a fixed point in time. Yet these 
estimates are simple approximations only. 
Individuals continually move into and out of 
dependence and abuse. Although these movements 
can be understood qualitatively, quantitative data 
at the national level lack the necessary density and 
precision for a full-scale dynamic analysis. 
Nevertheless, when joined with calculations of the 
social costs associated with drug problems, these 
population estimates provide a basis for further 
analysis of the drug treatment system and its 
adequacy. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 

THE INDIVIDUAL DRUG HISTORY: 
A MODEL AND OVERVIEW 

During any given month in the past 20 years, at 
least 14 million (in the peak months, more than 25 
million) individuals in the United States consumed 
some kind of illicit drug. Each of these 
individuals had a specific history of drug 
experience, in the context of unique biographical 
circumstances, yielding millions of different 
patterns of risks and consequences. To some 
degree, these patterns of drug behavior, context, 
and risk can be grouped according to familiar 
stereotypes. But even the stereotypes are highly 
diversified. For example, consider the differences 
among the following: 

■ a young teenager who lives in a welfare- 
supported, inner-city household with no adult 
male relatives present, sporadically attends 
junior high school but appears daily at a street 
venue to deliver crack-cocaine to customers 
(mostly adults) of an older gang member, and 
feels superior to these customers but has 
recently smoked some crack and marijuana 
laced with phencyclidine (PCP) several times 
with another young "dealer"; 

■ an adolescent college student from an affluent 
two-parent family, whose illicit drug 
experience is taking amphetamine pills to stay 
awake and cram for final exams and smoking 
marijuana with friends at house parties a few 
times during a semester; 

■ a single person in the mid-20s, steadily 
employed as an office manager, who takes 
amphetamines for weeks at a time as an 
appetite suppressant and uses marijuana or 
cocaine several weekend nights a month on 
dates or at parties; 

■ a divorced woman in her early 20s with two 
pre-school-age children, who supports herself 
mostly through welfare, intermittent 
prostitution, and larceny, which has led to 
several misdemeanor convictions and 
investigations by the family protective 
services office; she is currently pregnant and 



using crack-cocaine, marijuana, alcohol, 
and/or mood-lifting pills nearly every day by 
herself and with customers or boyfriends; 

■ a white-collar professional about 30 years old 
with a working spouse and no children, who 
has been snorting progressively larger 
quantities of powdered cocaine night after 
night (and increasingly, during the day) for 
several months— abstaining and crashing for a 
few days occasionally with larger than usual 
doses of alcohol; and 

■ a man in his mid-30s who was a childhood 
immigrant to the United States and has no 
fixed address or occupation, irregular contact 
with a common-law wife and children, and a 
20-year criminal record that includes 
burglary, armed robbery, assault, and drug 
sales convictions leading to extensive prison 
time; he is currently injecting heroin several 
times a day and supplementing that with 
cocaine, PCP, amphetamines, alcohol, and 
whatever else comes to hand; he is also 
seropositive for the AIDS virus. 

The treatment implications of these drug 
consumption patterns are quite different, and many 
individual variations cut across these stereotypes. 
To clarify clinical decisions and permit intelligible 
estimation of the overall need for treatment in the 
population, it is necessary to categorize drug 
consumers based on their current dose, frequency, 
and method of drug consumption, taking into 
account their past consumption patterns and 
weighing the severity of associated problems and 
consequences— including physical, emotional, and 
social problems. A conceptual paradigm of illicit 
drug consumption and responses is presented in 
Figure 3-1. 



42 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 



r 



Ces 












Aosnnence 




t 

sation 




" 


* 

Onset 








* 




Us© Low or infrequent doses: 
experimental, occasional, 
"social." Damaging consequences 
are rare or minor. 


* 


— 










* 




1 Intensification 








Abuse Higher doses and/or 
frequencies: sporadically heavy, 
intensive. Effects are unpredictable, 
sometimes severe. 


* 


— 


— 


*- 






* 




* 






1 Addiction 












Dependence High, frequent doses: 
compulsion, craving.withdrawal. 
Severe consequences are very likely. 






f-he 


* 
In" 




"Sel 


* 


rem 


ssion 

1 














Recovei 


ry 







r- - - ► 



Mild sanctions 
Prevention programs 



t 



(Early/light 

stage 

responses) 



(Late/heavy 

stage 

responses). 



Severe sanctions 

TREATMENT 
PROGRAMS 



L . 



RELAPSE 



I 



Indicates the Influence of biological, physiological, and 
social factors that condition changes In behavior. 



FIGURE 3-1 A model of individual drug history. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



43 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 

This scheme depicts the principal patterns or types 
of drug-taking behavior and orders them into 
common stages that, taken together, constitute a 
developmental pathway for individuals. Across 
large numbers of people, transitions from one 
stage to another can be summarized as risks or 
probabilities. These transition probabilities are 
heavily influenced by the interaction of two 
elements: the specific pattern of drug consumption 
and the presence of other biological, 
psychological, and social factors. 

Drug consumption is divided into three levels or 
stages commonly distinguished by clinicians and 
researchers: use, abuse, and dependence. (Other 
terms—for example, those used by the National 
Commission on Marijuana and Drug Abuse [1973] 
and Siegel [1992]— are related to this triad: 
experimental, occasional, or social/recreational 
use; intensified, regular, sporadically heavy or 
"binge" abuse; and compulsive or addictive 
behavior, which is dependence.) Each of these 
stages is, on average, more hazardous, more 
obtrusive, and more likely to provoke or induce 
social interventions (e.g., punitive sanctions, 
attention by prevention programs, admission to 
treatment) than the one before. 



Abstinence, Drug Types, 
and Normative Attitudes 



Prior to drug consumption, there is abstinence. 
Abstinence here is defined behaviorally and means 
not seeking out, not consuming, and not being 
impaired as a result of having consumed 
psychoactive drugs. Abstinence so defined is 
usually but not necessarily the same as being 
physiologically "drug-free," which refers strictly to 
the absence of pharmacological effects or traces of 
drugs or their metabolites. Taking psychoactive 
drugs under legitimate medical supervision at 
prescribed doses for generally recognized 
therapeutic purposes does not in itself violate 
abstinence. 

Federal and state codes define specific 
psychoactive drugs by their chemical names, 



dividing them into several classes of controlled and 
proscribed substances (Table 3-1). Some drugs, 
such as the volatile solvents in model airplane 
glue, are virtually uncontrolled. Others, such as 
nicotine (in tobacco) and alcohol, are legally 
available to those above certain ages but only 
under circumscribed terms and conditions, 
including various situational prohibitions (e.g., 
tobacco smoking is prohibited in many public and 
commercial locations, drinking of alcohol is 
prohibited while driving) . Because of the partial 
legality of alcohol and tobacco, little attention is 
paid in this report to their use, abuse, or 
dependence except in conjunction with illicit drug 
consumption. 

Abstinence from illicit psychoactive drugs is 
normative— that is, legally and morally 
unquestioned by most people most of the time. 
But social norms are much less homogeneous 
across social groups or situations than are legal 
definitions, and they are subject to change across 
time. The shifting normative status of marijuana 
among young middle-class Americans over the past 
25 years is a good illustration. The overall degree 
of normative chill attached to illicit drug 
consumption varies from slight to grave depending 
on the details, gradations similar to the moral 
index applied to other classes of illegal acts 
ranging from traffic infractions through mass 
murder. For example, when a public sample was 
asked about the severity of crimes, only 
homicide/manslaughter and forcible rape were 
rated as worse offenses than selling cocaine 
(Jacoby and Dunn, 1987, cited in Flanagan and 
Jamieson, 1988). Using cocaine, however, was 
seen as comparable in severity to drunk driving 
without an accident or thefts or burglaries of 
moderate amounts of goods— serious crimes but 
much lower on the scale. In a 1986 opinion 
survey in which 96 percent of respondents 
disagreed with the statement that all illicit drugs 
should be made legal, 85 percent agreed that "the 
best place for most drug abusers is a drug 
treatment program and not jail" (Flanagan and 
Jamieson, 1988:194). 



44 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 



TABLE 3.1 


Classification of Psychoactive Drugs 




Class 

a 


Examples Effects for Which 

Used 


Other Possible Effects 



Opiates 



Heroin, morphine, 

methadone, 

codeine 



Euphoria, relaxation, 
mood elevation 
(reduction of pain, 
anxiety, aggressive or 
sexual drives) 



Drowsiness, respiratory 
depression, nausea 



Depressants 


Barbiturates, 


Like alcohol: 




methaqualone, 


euphoria, relaxation, 




(Quaalude) 


mood elevation 




diazepam, 






(Valium) 




Stimulants 


Cocaine, 


Euphoria, alertness, 




amphetamine, 


sense of well-being, 




nicotine, 


suppression of fatigue 




methylphenidate 


and hunger, increased 
sexual arousal 


Hallucin- 


LSD, 


Vividly altered 


ogens 


mescaline, 


perception, 




psilocybin, 


detachment from self 




MDA 




Phencycli- 


PCP, 


Detachment from 


dines 


ketamine 


surroundings, 



numbness, distorted 
perceptions, illusions 
of strength 



Drowsiness, mood 
volatility, respiratory 
depression, nausea, 
impaired coordination, 



Increased pulse and blood 
pressure, tremor, insomnia, 
paranoia, psychosis, 
cardiac arrest 



Increased blood pressure, 
tremor, impaired judgment 
and perceptions of time 
and distance, panic 
reaction 



Anxiety, impaired 
coordination, paranoid 
delusions 



Cannabinoids 



Inhalants 



Marijuana, 
hashish 



Acetone, 
benzene, 
nitrous oxide, 
butyl nitrate 



Euphoria, relaxation, 
altered perceptions, 
increased sexual 
arousal 

Euphoria, giddiness, 
illusions of strength, 
distortions of visual 
perception 



Increased appetite, 
disorientation, impaired 
judgment and coordination, 
paranoia, headaches 

Hallucinations, slurred 
speech, drowsiness, 
headache, nausea, 
respiratory depression, 
cardiac arrest 



NOTE: The effects of different compounds within each drug class differ in duration and in the specific combination of effects. In 
addition, the responses to a drug vary according to the dose level, the drug taker's prior experience with the drug, including current 
tolerance, the drug taker's prior mental and physical condition, and the situation. The effects of a drug change from immediate 
reaction across time to the clearing of extended responses, which may involve withdrawal symptoms after chronic use. 



NIDA DRUG ABUSE SERVICES RESEARCH SER/ES, No. 2 



45 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



Learning and Drug Experience 

An individual drug history is most readily 
understood as a sequential learning experience. 
An individual cannot know beforehand exactly 
how a drug will affect him or her because there is 
great variability in this response, depending on the 
drug and the specific dose exposure, the 
individual's biological and psychological state, and 
the social circumstances (Levison et al., 1983). 
Every naturally occurring or synthetic 
psychoactive drug affects the brain and other 
nervous tissue by mimicking, displacing, blocking, 
or depleting specific chemical messengers between 
nerve cells, called endogenous neurotransmitters. 
Most drugs directly affect one or several of the 
numerous neurotransmitter systems, but the brain 
is so complex and interlinked that many functions 
may be significantly affected by action on a single 
type of messenger/ receptor system. These dose- 
dependent metabolic effects are responsible for a 
number of phenomena: immediate changes in 
mood, thinking, and physiological states; medium 
and longer term neuroadaptation such as increased 
tolerance to some (but not all) drug effects; and, in 
some cases, persistent or irreversible changes in 
brain functioning or memory. (Such changes are 
not necessarily strange or ominous; strong 
memories of any kind produce persistent changes 
in the brain.) 

Some drug effects are hard to duplicate without the 
drug's presence; other effects differ, if at all, only 
quantitatively (that is, in how rapid, long-lasting, 
or uniform the effects are across individuals) from 
the way other kinds of stimuli can affect the brain 
(e.g., motion, touch, sights and sounds, including 
human communication). Drug effects depend 
heavily on the dose, the route of administration 
(smoking and intravenous [IV] injection are very 
fast; snorting, chewing, drinking, or eating, rather 
slow), previous exposure, and other characteristics 
of the individual consumer, including what he or 
she expects the drug to do. The metabolic 
mechanisms of drug action in humans are shared 
with some other mammalian species, which has 
been a basis for developing animal models that 
have been important sources of scientific insight 
and testing. 



Some individuals respond quite positively to their 
initial drug experience; 1 others react quite 
negatively (experiencing nausea, paranoia, or a 
painful drug hangover). Still others react with 
puzzlement: "Well, that's different— but what's all 
the fuss about?" There are various reasons for 
these different responses, but their relative 
importance is uncertain. Not only the drug's 
metabolic effects, modulated by the individual's 
chemistry, but also the associated circumstances 
and activities, filtered through the individual's 
personality, shape the initial response to drugs, 
creating different degrees of satisfaction or 
discomfort. If the individual continues to use 
drugs— which may occur even if the initial trial is 
not rewarding, as a consequence of continued 
curiosity, local custom, or peer pressure— a history 
of experience is built up, a learning curve, in 
effect, that can lead in different directions 
depending on the specifics of the individual's 
experience. 

The balancing of pleasurable or rewarding 
experiences and punishing or unpleasant 
experiences that occurs during the early weeks or 
months of drug involvement may be of critical 
importance. If the net impact of those experiences 
is highly positive, the effect or memory of that 
"honeymoon" can remain remarkably strong over 
time, even as continuing reward diminishes and 
punishment increases, especially if alternative 
competitive behaviors are not exercised or 
reinforced as strongly. Social interventions 
directed toward the individual— criminal penalties, 
job-related or family sanctions, prevention 
programs, and treatment programs— contribute to 
the learning history, but precisely how depends on 
the details of that individual's experience (Ray, 
1988). 

Added to the specific hazards associated with each 
stage of drug use are the risks of transition to 
further stages. Each stage entails some chance of 
progression to the next, although progression is 

'in dramatic terms: "It's so good, don't even try it once." 
Although this exhortation mimics current beliefs about crack- 
cocaine, it is actually a quotation about heroin (Smith and Gay, 
1972). 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREA TMENT 



not inevitable. A minority of experimental users 
intensify their consumption to the level of abuse; 
fewer yet advance into dependence. Nevertheless, 
the entire U.S. population, even abstainers, can be 
viewed ^as incurring some risk from drug 
consumption: even those who have never used 
drugs are slightly at risk by virtue of drugs being 
available to them (in an ever-active market) and by 
virtue of the behavior of drug users in their 
environment. 



subjective point of view, drug-seeking behavior 
seems highly volitional during initiation and early 
use; this voluntary period, however, is profoundly 
influenced by the conditions and responses of other 
people in the immediate vicinity and by individual 
variation in how drugs affect the brain and 
personality. 



Environmental Variations 



What the drug consumer learns through drug 
experience takes the specific form of tendencies to 
seek drugs. That pattern, at least, is what the 
observer sees; the consumer often defines this 
"tendency" as something else— a habit, interest, 
hunger, or craving. These drug-seeking tendencies 
vary in when they are expressed as well as how 
forcefully —that is, how effectively the tendency to 
seek drugs competes with other behaviors. The 
tendency may be entirely dormant unless some 
condition or cue evokes it. Cues may be purely 
internal or set off by external contingencies. 
Purely internal cues could be physiological 
sensations owing to earlier drug exposure— for 
example, immediate or delayed withdrawal 
syndromes— or they may be moods, thoughts, or 
sensations that were associated in time or meaning 
with taking drugs. These phenomena are as varied 
as individual biography: for one person, pain, 
distress, or sadness may lead to drug craving; for 
another, feelings of pleasure, including the 
pleasure of certain company, may evoke the 
response; for yet another, waking up in the 
morning and going to bed at night may produce 
this effect. Times, places, people, objects— any 
association with earlier drug taking may evoke 
drug craving, and the closer the link, the stronger 
the cue. 

The mixture of drug effects that consumers seek, 
or are satisfied with, tends to change subtly over 
time, moving typically from just "getting high" or 
being sociable in the early stage of use to the 
achievement of temporary relief from the persistent 
desire or learned need for a drug (a desire that 
persists even after short-term withdrawal is 
completed) in the stage of dependence. From a 



There is a range of individual susceptibility to the 
learning of drug-seeking behavior that would be 
seen clearly if environmental conditions were held 
constant. But social environments are not 
constant; indeed, variation in social environmental 
conditions correlates strongly with demographic 
and geographic variations in drug use, abuse, and 
dependence rates. Other factors that affect drug- 
seeking behavior are the contexts and conditions of 
availability of different drugs (e.g., cocaine, 
heroin, marijuana, and amphetamines) as well as 
the new technologies and marketing organizations 
that are periodically introduced. 

Cocaine is a good example. Cocaine is a chemical 
in the leaf of the coca plant that functions for the 
plant as a pest repellent. Human societies in the 
Andean region have used the coca leaf as a 
stimulant in low but effective oral doses (often by 
chewing the leaf, although there are a variety of 
preparations) for about 5,000 years, both as an 
ordinary tonic and in various medicinal and 
ceremonial applications. By 1860 the cocaine 
alkaloid (base, or free-base) had been isolated and 
extracted; a few decades later, its water-soluble 
salt, cocaine hydrochloride, became widely 
popular in Europe and the United States. Cocaine 
hydrochloride was offered in a variety of 
commercial preparations, including cocaine 
snuffing powder, coca cigars, coca wines, Coca- 
Cola, and injectable solutions. This epidemic of 
popular use ended with the onset of better medical 
knowledge regarding the substance, pharmaceutical 
regulation, and criminal sumptuary laws motivated 
by strong racial fears. Cocaine was confined to 
the underworld, where it was used mostly by 
injection along with heroin. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



CO 
CO 

> 

CC 
UJ 

a 
z 
< 

CO 

o 

I 

tr 

UJ 
0. 

CO 
CO 

> 
o 

D 
CC 
O 



7 
6 
5 
4 




Cocaine 
Heroin 




Hallucinogens 
Amphetamines 




FIGURE 3-2 Drug visits to emergency rooms (ER) by selected cities and drugs, 1987. 
DAWN = all cities reporting to the Drug Abuse Warning Network. Source: National 
institute on Drug Abuse (1988a). 



43 



NIDA ABUSE SERVICES RESEARCH SERIES. Ho. 2 



THE NEED FOR TREA TMENT 



Cocaine reemerged in the 1970s, mainly as an 
expensive snuffing powder. There was also a brief 
vogue of desalting the powder to return it to the 
free-base, heating it to vaporization, and inhaling 
the vapor (smoking it). More recently, cocaine 
base has been brought directly to market as "rock" 
or "crack. " As a result of large-scale investments 
in cultivation, manufacture, and smuggling 
protection in the early 1980s, the product became 
widely available, packaged for street sale in a 
number of large urban areas in as small as single- 
dose amounts. 

The drifting of cocaine consumption between 
popularity and insularity, and through different 
technologies and recipes, is not atypical of 
ethnopharmaceuticals, although every drug has its 
own particular industrial and epidemiological 
history. As well as differences across time, there 
are differences from place to place at the same 
time. The Drug Abuse Warning Network 
(DAWN), which has tracked the ebb and flow of 
different drugs in the United States for 
approximately the past 15 years, reveals very 
different comparative levels of severe drug 
reactions, and, by implication, of abuse and 
dependence patterns, in large U.S. cities (Figure 3- 
2). Although there are relatively small differences 
among Hispanic, white, and black U.S. population 
groups in the overall use of illicit drugs, these 
differences are much larger for the consumption of 
specific drugs. 



Age of Onset and Drug Sequencing 

The onset of drug use has been studied fairly 
extensively. Two salient findings common to 
surveys of youth, the general population, treatment 
enrollees, and prison populations involve the age 
of onset of use and the sequence of drug 
involvement. The bulk of initial, experimental 
drug usage occurs during the teenage years. Very 
few children aged 10 or younger have begun to 
use drugs. Nearly as few people begin using 
drugs— or even any particular type of drug, unless 
it was never previously available— after reaching 25 
years of age. (There is increasing concern about 



abuse and dependence syndromes among elderly 
individuals, but those conditions are largely the 
result of the escalated use of alcohol and 
prescription drugs.) 

Most new users of any drug do not progress very 
far, and there are often shifts from intermittent use 
back to abstinence. The use stage may continue 
for a long period, or it may be transitory; the 
individual may return to long-term abstinence 
either in response to some form of intervention or 
direct persuasion or on his or her own initiative. 
The earlier drug use begins, however, the more 
likely it is to progress to abuse or dependence; the 
later it begins, the more likely it is to "tail off" 
into renewed abstinence without further 
progression or, if progression occurs, to yield to 
earlier, more sustained recovery. 

Cessation without intervention does not necessarily 
imply a self-contained decision that "drugs are 
bad." A convenient source of a favored drug may 
disappear, and new sources may prove undesirable 
or too costly. Alternatively, an individual may 
cease drug use as a result of social circumstances 
(changing friends, falling in love with someone 
who does not use or approve of drugs, marriage, 
child-raising, and job responsibilities; Schasre, 
1966; Waldorf, 1973; Eldred and Washington, 
1976; Robins, 1980; Kandel and Maloff, 1983) 
that leave little time for evening bar-hopping and 
party-going. Another incentive for cessation may 
be learning about previously unsuspected hazards 
through news stories or by personal observation 
(Johnston, 1985). For many years, introduction to 
drugs in the majority of cases has proceeded in a 
general, cumulative sequence: tobacco and 
alcohol, to marijuana, to other inhalable or orally 
ingested substances, to hypodermic injection of 
opiates or powerful stimulants (cocaine, 
amphetamines). 2 This sequence is almost always 

2 Drug preparations are often contaminated with biologies or 
adulterants. When the needle route is used and injection 
equipment is reused without thorough cleaning, transmission of 
infectious diseases is common. AIDS is the best known and 
most feared of such diseases, although hepatitis and heart 
infections are very commonly transmitted. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



initiated between the ages of 12 and 15; the 
injection phase, when reached, generally begins 
between the ages of 17 and 20. The sequencing 
phenomenon is thought to reflect two factors: 
drug availability and the degree of opprobrium 
attached to the respective drug types. As cocaine's 
marketing expands and marijuana's diminishes, the 
sequence of introduction to these drugs may 
become less uniform. 

There are multiple theoretical reasons for these age 
and sequential uniformities, but the data are 
insufficient to scale these reasons precisely 
according to strength, distribution, or importance. 
The most frequently advanced explanations for the 
uniformity of adolescent onset are sociological and 
biological: adolescence is a period of transition 
between childhood dependency and adult self- 
responsibility; in many cases, the continuous adult 
supervision characteristic of childhood diminishes 
substantially; errors in newly enfranchised 
judgment— exercised as "trying out identities," 
"testing limits," and "rebelling"— are more widely 
tolerated or permitted among adolescents than 
among children or adults; adolescents grow 
quickly to nearly adult size and mobility, 
experiencing strong passions and desires ("raging 
hormones") that they are slow to learn how to 
channel and control. Whatever the reasons, a 
variety of mildly to seriously deviant behaviors 
(e.g., sexual profligacy, suicide attempts, 
assaultive behavior with weapons, thievery for 
profit) begin to occur at these ages. 

If progression occurs (from use to abuse to 
dependence), it generally takes from 5 to 10 years 
following the first experimental use of any drug— in 
the late teens or early 20s— and from 1 to 4 years 
following the experimental use of the particular 
drug that is being consumed in a dependent 
manner (Brown et al., 1971; Robins, 1980; Kandel 
and Maloff, 1983; White, 1988; Kozel and Adams, 
1985). Progression seems to be more rapid with 
stimulants such as cocaine and amphetamines than 
with other types of drugs. 

Typically, the initial voluntary component of 
drug-seeking behavior is compromised by the 
cumulative physiological, psychological, and social 



effects of the dependence process. The 
conditioning of behavior by physiological and 
psychological drug effects and by the distribution 
of rewards and punishments in the proximate 
social environment can conspire to steadily 
undermine the individual's ability to control the 
level and timing of drug consumption. Eventually, 
continued high-frequency drug consumption 
behavior becomes so ingrained that the individual 
must explicitly unlearn it. Some individuals 
achieve such unlearning by trial and error; most 
drug-dependent individuals are unable to do so and 
thus discover they need help to unlearn their drug- 
seeking habits (i.e., to successfully extinguish 
drug-seeking behavior). 



Diagnosing Dependence and Abuse 

Drug treatment is not designed for the low- 
intensity drug user who is readily able to control 
his or her level of consumption and for whom 
functional consequences have not yet accumulated. 
When progression to abuse occurs, the less 
intrusive ambulatory drug treatments are generally 
brought to bear. The most resource-intensive 
modalities, which involve extended 
pharmacological interventions or residential stays, 
are designed principally to treat drug dependence. 

The importance of these distinctions has led 
clinicians and researchers to try to develop clear, 
standardized criteria for abuse and dependence. 
These criteria are most fully described in two 
authoritative, multiyear, multidisciplinary 
collaborative efforts built on extensive literature 
reviews and trials in research and clinical practice: 
the forthcoming 10th edition of the International 
Statistical Classification of Diseases, Injuries and 
Causes of Death (IDC-10), a product of the World 
Health Organization, and the 3rd revised edition of 
the Diagnostic and Statistical Manual of Mental 
Disorders (DSM-III-R), published in 1987 by the 
American Psychiatric Association. In codifying 
diagnostic criteria for abuse and dependence, both 
classification systems have converged on 
formulations that emphasize two fundamental 
observations. 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 



TABLE 3.2 Correspondence Between the Criteria for Dependence" of the International 
Statistical Classification of Diseases, Injuries, and Causes of Death (10th rev.; ICD- 
10) and the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; 
DSM-III-R) 



ICD-10 



DSM-III-R 



Progressive neglect of alternative pleasures or 
interests in favor of substance use. 



Important social, occupational or recreational 
activities given up because of substance use. 



Persisting with drug use despite clear evidence of 
overtly harmful consequences. 



Continued substance use despite knowledge of 
having a persistent or recurrent social, 
psychological, or physical problem that are caused 
or exacerbated by the use of the substance. 



Evidence of tolerance such that increased doses 
of the substance are required in order to achieve 
effects originally produced by lower doses. 



Substance use with the intention of relieving 
withdrawal symptoms and subjective awareness 
that this strategy is effective. 

A physiological withdrawal state. 

Strong desire or sense of compulsion to take 
drugs. 



Marked tolerance: need for markedly increased 
amounts of the substance in order to achieve 
intoxication or desired effect, or markedly 
diminished effect with continued use of the same 
amount. 

Substance often taken to relieve or avoid 
withdrawal symptoms. 



Characteristic withdrawal symptoms 

Persistent desire or one or more unsuccessful 
efforts to cut down or control substance use. 



Evidence of an impaired capacity to control drug 
taking behavior in terms of its onset, termination, 
or level of use. 



Substance often taken in larger amounts or over 
a longer period than the person intended. 



A narrowing of the personal repertoire of patterns 
of drug use, e.g., a tendency to drink alcoholic 
beverages in the same way on weekdays and 
weekends and whatever the social constraints 
regarding appropriate drinking behavior. 



Frequent intoxication or withdrawal symptoms 
when expected to fulfill major role obligations at 
work, school, or at home or when substance use 
is physically hazardous. 



Evidence that a return to substance use after a 
period of abstinence leads to a rapid 
reinstatement of other features of the syndrome 
than occurs with nondependent individuals. 



A great deal of time spent in activities necessary 
to get the substance, taking the substance, or 
recovering from its effects. 



"A dependence syndrome is present if three or more criteria are met persistently (DSM: continuously) in the previous month or some time 
(DSM: repeatedly) in the previous year. 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



First, the criteria for dependence and abuse (the 
latter is called "harmful use" in ICD-10) apply 
uniformly to all psychoactive substances, which 
emphasizes the commonalities in drug-related 
behavior, physiology, and cognition or subjective 
awareness. The more specific pharmacological 
effects and sociolegal status of each substance are 
recognized but do not directly affect the diagnosis. 
Second, both schemes concede the irreducible 
complexity of drug phenomena. Rather than 
offering a single file of descriptors that every 
positive diagnosis must match (e.g., the classical 
signs of tolerance and withdrawal), the two 
systems lay out an array of functionally significant 
problems, diverse formations or combinations of 
which are accepted as equally significant for 
diagnostic purposes. Perhaps a small monument to 
this complexity is the fact that, despite cross- 
consultation between the two projects, and 
although each retains the same number of defining 
criteria (nine), there are various differences 
between them in shades of meaning (Table 3-2). 

The convergence is most complete in defining the 
dependence syndrome: in the ICD-10, it is a 
cluster of physiological, behavioral, and cognitive 
symptoms or phenomena such that "the use of a 
drug or class of drugs takes on a much higher 
priority for a given individual than other behaviors 
that once had a higher value"; the DSM-III-R 
defines it as when "the person has impaired control 
of psychoactive substance use and continues use of 
the substance despite adverse consequences." A 
positive ICD-10 diagnosis is triggered when three 
or more criteria are present at some time in the 
previous year or continuously during the previous 
month. Similarly, any three DSM criteria 
precipitate the diagnosis of dependence. There are 
also degrees of dependence— mild, moderate, and 
severe— based on the number of symptoms 
observed above the minimum criterion level and in 
particular the extent of social and occupational 
impairment. Diagnostic specifications for partial 
and full remission are also part of the classification 
schemes. 

Abuse is a lesser category in both schemes. In 
DSM-III-R, psychoactive substance abuse is 
defined as follows: the persistence of psychoactive 



substance use for at least one month or repeatedly 
over a longer period of continuing use despite the 
recurrence or persistence of one or more known 
adverse consequences (social, occupational, 
psychological, or physical) or the taking of 
recurrent physical risks such as driving while 
intoxicated. The substance abuse diagnosis is 
triggered only if the person has never met the 
criteria for dependence for this substance. ICD-10 
diagnoses "harmful use" when there is clear 
evidence that the consumption of a substance or 
substances is responsible for causing the user 
actual psychological or physical harm— negative 
social consequences (e.g., arrest, job loss, marital 
breakdown) are not considered psychological 
harm. (If, however, these negative consequences 
in turn cause psychological harm, it is unclear 
whether the pattern of use would then be deemed 
harmful.) The ICD-10 scheme puts less emphasis 
than DSM-III-R on the importance of earlier drug 
history; previous dependence does not preempt a 
current finding of the lesser diagnosis, as it does in 
the DSM system. 

The critical commonality in these definitions and 
measures is that these criteria focus on impairment 
of control and undesirable functional consequences 
of excessive drug consumption. These 

consequences may range from health problems to 
lost social opportunities, but they are alike in that 
they are unwanted. Indeed, individuals who 
become dependent are dismayed by the negative 
effects of their drug consumption. When the doses 
and schedules of use become dense enough, they 
take on a life of their own, which can impair an 
individual's capacity to reduce or cease drug use in 
spite of accumulating harm. Helping to strengthen 
this capacity for choice or self-control over drug 
seeking— particularly when the individual lacks the 
protection of confinement (e.g., closed hospital 
wards or prisons) where there is limited 
opportunity to exercise choice— is the object of 
virtually all interventions (including mutual self- 
help groups) to rehabilitate drug-abusing and drug- 
dependent individuals. To achieve this goal, it is 
often necessary to help develop other capabilities 
(or to heal other disorders or damages) so that 
alternative ways of behaving become more 
accessible and their rewards easier to reap. 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREA TMENT 



Recovery and Relapse 

Dependence sometimes lasts indefinitely but slowly 
increases in severity. More typically, however, 
dependence is interrupted, followed (after several 
months to several years of drug use) by some 
period of recovery. 3 Although recovery is similar 
to abstinence in that drugs are not sought or used, 
the previous experience of dependence or extensive 
abuse leaves a variety of powerful residues. There 
may be craving and other strong drug-related 
emotions and sensations, which may take months 
to recede. There may also be permanently 
disabling physical illnesses and wounds. There 
will certainly be conditioned behavioral tendencies 
and responses closely associated with drug taking 
that are slow to extinguish fully and must be 
specifically countered if recovery is to last. A 
recovering individual may have to scrupulously 
avoid certain locations, situations, or people who 
were strongly associated with drug acquisition. 
The individual may carry indelible social stigmata, 
such as a record of criminal convictions. And 
there may be other losses created or aggravated by 
drug involvement: years without conventional 
employment, lack of formal education, 
irremediable family divisions, and deep emotional 
wounds. 

Recovery is not an easy process, and first, second, 
or later episodes may be followed by relapse. 
Cycling one or more times from recovery back 
through relapse to dependence or abuse (more 
rarely, to low-level use) is so common that it must 
be seen as an intrinsic feature of the natural history 
of individual drug behavior. 

Individuals may follow any one of a range of 
courses after an initial period of abuse or 
dependence. There is a cumulative literature on 
one such course that Winick (1962) called 
"maturing out" of drug dependence. Although 

'The term recovery is equivalent to the term remission generally 
used in clinical descriptions of other chronic relapsing disorders. 
Recovery is used more commonly in the alcohol and drug field 
and suggests the more active character of the recovery 
process, in contrast to the passivity implied by remission; that 
is, a disorder remits, but an individual recovers. 



that description of recovery is now viewed as too 
restrictive and therefore misleading, it does 
suggest the decades-long span across which the 
cycle of drug dependence/recovery/relapse can 
continue. The bulk of the literature on cycles of 
dependence and recovery concerns heroin, the 
major drug of dependence of the 1950s and 1960s; 
it is not yet known whether long-term patterns of 
dependence on the major drugs of the 1970s and 
1980s, marijuana and cocaine, will be similar. 
There are strong reasons to think that the heroin 
literature is a good guide, including the fact that 
findings regarding recovery and relapse from 
alcoholism resemble findings in the heroin 
literature. 

The classical study of recovery and relapse from 
heroin addiction prior to the availability of modern 
treatment modalities was carried out by Vaillant 
(1973), who followed 100 heroin addicts from 
New York City who were admitted to Lexington in 
the early 1950s. For most of the study period, the 
only form of drug treatment available was 
detoxification. Yet the prevailing criminal 
approach to drugs, symbolized in New York by 
the Rockefeller "get tough" drug laws, guaranteed 
that there were powerful environmental incentives 
toward recovery. The results for this cohort are 
displayed in Figure 3-3. The number of actively 
heroin-dependent members declined as the cohort 
aged, but many remained until they died in a cycle 
of dependence, brief recovery (often while in 
prison only), and relapse. Deaths occurred at a 
sustained rate of approximately one per year-- 
roughly the same as if this cohort of 100 men had 
been about 50 years old on average instead of less 
than 25 years old at the beginning of the period. 
Many became virtually permanent prison inmates 
as a result of unabated heroin use and other 
criminal behavior. 

As these data and much subsequent research (e.g., 
McGlothlin et al., 1977; Nurco et al., 1981a,b,c) 
powerfully argue, dependent drug-seeking behavior 
and its subjective aspect, the strong desire or 
craving for drugs, are difficult to extinguish once 
they have been established in a familiar drug- 
supplying environment. Nevertheless, some 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



proportion of individuals succeed in eliminating an 
established, chronic pattern of dependent behavior. 
Studies indicate that there is usually a complicated 
path to sustained recovery, more often than not 
involving one or more relapses. Individuals with 
severe problems (e.g., family disintegration, 
illiteracy and other educational failings, lack of 
legitimate job skills, psychiatric disorder) continue 
to have these difficulties (especially if they precede 
drug involvement) unless specific help is received 
to deal with them. Such problems disrupt the 
process of unlearning (that is, learning self-control 
over) drug-seeking habits and responses; 
consequently, these disadvantaged individuals are 
at intrinsically higher risk of relapse than persons 
with fewer or less severe problems. 

The number of high-quality, long-term studies of 
recovery from dependence is relatively small, but 
the results have been consistent. Although many 
people do recover from dependence, recovery is 
seldom achieved, or even begun, before the 
individual recognizes that he or she has suffered 
and caused significant personal and social harm. 
Some proportion of individuals who are (or would 
be) diagnosed as drug abusing or dependent— a 
proportion that may vary somewhat with the 
specific drug and especially with the level of 
problem severity— recover without treatment. The 
evidence suggests that successful, nontreated 
recoveries are most likely to occur when the level 
of consumption and problem severity is low and 
the individual has (or gains) close friends and 
relatives— perhaps including coworkers, employers, 
or fellow members of mutual self-help groups— 
who provide daily support, encouragement, and 
disciplined help in avoiding relapse and engaging 
in non-drug-related activities. This kind of social 
support increases the chance of recovery whether 
or not formal treatment is received. 



may undergo treatment who would otherwise 
recover even without it but perhaps at a slower 
rate. It is clinically sensible to titrate the intensity 
of the prescribed treatment to some degree 
according to the severity of the condition, the 
degree of preexisting social and personal support 
available to the individual, and the number of 
earlier attempts at untreated recovery. The need 
for treatment is clearest, and the indication for 
intensive treatment measures strongest, in cases of 
severe dependence and prior relapses. 

The second implication of the inability to clearly 
discriminate those who may not need treatment in 
order to recover involves treatment evaluation. If 
a form of drug treatment contributes effectively to 
the recovery of various individuals who are so 
treated, it basically increases the overall group rate 
of recovery over what would have occurred in the 
absence of treatment. Evaluation of treatment 
effectiveness therefore depends not only on 
adequately describing the form of treatment and 
measuring the outcomes among those treated but 
also on being able to estimate the untreated 
recovery rate for that group. In practical terms, 
this means identifying the outcomes in an 
appropriate untreated comparison group. There 
are other ways to test treatment effectiveness— for 
instance, investigating whether larger doses of 
treatment have more effect than smaller doses, up 
to the prescribed limit or an optimum. 
Nevertheless, an untreated comparison group 
offers the ultimate test. This important 
methodological issue is discussed in Chapter 5. 



ESTIMATING THE EXTENT OF 
THE NEED FOR TREATMENT 



There is as yet, however, no way of discerning 
who will or will not recover without treatment or 
over what time frame recovery will proceed, and 
this discrimination deficit has two important 
implications. First, it is reasonable and ethically 
incumbent to presume that treatment is needed 
whenever abuse or dependence is present, even 
though this presumption means some individuals 



Diagnosing drug abuse or dependence in an 
individual based on history-taking, physical 
examination, and the information in previous 
records is a different matter from estimating how 
many individuals in the general population meet 
such diagnostic criteria. Individual histories have 
never been taken and physical test batteries for 
drug problems have never been performed on a 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 



100 rc 



Z 
Ul 
O 
CC 
Ul 
Q. 




5 10 18 

YEARS 
FIGURE 3-3 Status of 100 heroin addicts at three points in time after index hospital discharge. 

Source: Vaillant (1973). 



X 

III 
Q 




FIGURE 3-4 Trends in cocaine, heroin, and marijuana involvement in deaths and medical emergencies, 

1976-1988. Index Year 1985 = 100. Sources: National Institute on Drug Abuse (1987); National Narcotic* Intelligence Consumer 
Committee (1989). 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



fully representative sample of the whole U.S. 
population. A number of partial population studies 
have been conducted in the 1980s, however, and, 
taken together, these surveys provide a basis for 
estimating the extent of the need for treatment. 

The most clinically sensitive population study was 
conducted using the DSM-III Clinical Research 
Diagnostic Criteria. Nationally adjusted 

prevalence estimates from household interviews in 
five metropolitan areas for 1981-1983 (Regier et 
ah, 1988) indicated that, in a given month, 2.3 
million adults— about 1 percent of the adult 
population— would have met the clinical criteria for 
a diagnosis of drug dependence or abuse. These 
authors further concluded that, over a 6-month 
period, a total of 3.4 million adults would have 
met these criteria because individual drug 
problems (and particularly patterns of abuse) 
undergo change across even this short a time span. 

For the Presidential Commission on the Human 
Immunodeficiency Virus Epidemic (1988), the 
National Institute on Drug Abuse used 1985 
household survey data (which were cruder than the 
Regier team's five-city instrument) to estimate that 
6.5 million persons "used drugs in a manner which 
significantly impair[ed] their health and ability to 
function." More recently, for the September 1989 
National Drug Control Strategy document (Office 
of Drug Control Policy, 1989), NIDA used the 
1988 household survey conducted by the Research 
Triangle Institute (NIDA, 1989) to estimate that 4 
million persons (about 2 percent of the population 
aged 12 or older) had taken drugs 200 times in the 
past 12 months, thus defining the population most 
clearly in need of treatment. 

These variations not only reflect divergent methods 
of estimating the need for treatment but also show 
that the extent of need is not static. One good 
indicator of this changing picture is provided by a 
data series collected since 1976 from local 
emergency rooms and medical examiners in cities 
around the country. The series consists of 
incidents in which specific drug involvement was 
noted in medical reports that specifically called for 
this information. Figure 3-4 reports indices for 
cocaine, heroin, and marijuana from 1976 to 1988 



in consistently reporting medical units, 
standardized to the 1985 value. The cocaine and 
heroin indices are an average of emergency room 
and medical examiner cases; marijuana is based on 
emergency room reports only. The paths of the 
three drugs have varied during the 12-year period, 
but all are clearly at higher levels in 1988 than in 
1976— for cocaine, dramatically higher. These 
indices of severe drug problems project a very 
different picture from that seen in data tracking all 
current use (once or more in the past month). 
This type of threshold prevalence data, displayed 
in Figures 3-5a, 3-5b, and 3-5c for three age 
strata, shows quite a different set of trends for 
marijuana and cocaine across the 1980s, 
particularly among adolescents and young adults. 

The committee has developed new estimates of the 
need for treatment by combining information from 
three data sources: the 1988 NIDA/RTI national 
household population survey; a number of surveys 
and longitudinal studies of criminal justice 
populations conducted or sponsored by the Bureau 
of Justice Statistics and the National Institute of 
Justice; and recent studies of the homeless 
population. 



Household Survey Data 

National drug use surveys to collect data from 
probability samples of U.S. household residents 
have been conducted at intervals of from one to 
three years since 1972. The 1988 survey of 5,719 
adults and 3,095 adolescents, conducted by the 
Research Triangle Institute for NIDA, was the first 
to collect information on items that are part of the 
ICD-10 and DSM-III-R criteria for drug 
dependence and abuse. A thorough assessment of 
the reliability and validity of these survey items, 
including cross-validation with clinical work-ups or 
diagnostic interviews, has not been performed. 
Nevertheless, it is possible to use responses to 
relevant survey items on symptoms of dependence, 
negative consequences or problems attributed to a 
drug, and levels of drug consumption to estimate 
more precisely than in previous efforts the need 
for treatment among household residents. 



56 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 




YEAR 




72 74 



8 80 82 84 86 88 



Marijuana 




FIGURE 3-5. Trends in past-month drug use, 1972-1988 for (a) adolescents aged 12 to 17 years; (b) 
young adults aged 1 8 to 25 years; (c) adults aged 25 and older. Not*: The stimulant iin* \» miMing in tn* figure* 

where frequencies ware too low for statistical reliability- Source: National Institute on Drug Abus* (1988b. 1989). 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1. CHAPTER 3 



Clear (10.4%) 



Probable 
(21.6%) 




Unlikely 
(47.7%) 



Possible (20.3%) 



FIGURE 3-6 The estimated need for treatment among the 1988 household drug- 
consuming population (14.5 million individuals in the household population who had 
used drugs at least once in the past 30 days). Source: Institute of Medicine analysis 
of data from the 1988 National Household Survey on Drug Abuse, performed by 
Research Triangle Institute for the National Institute on Drug Abuse. 



58 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 



The data on each individual in the survey were 
classified to yield categories of clear, probable, 
possible, and unlikely need for treatment. Clear 
need was defined in terms of exceeding thresholds 
on three distinct criteria: illicit drug consumption 
at least three times weekly; at least one explicit 
symptom of dependence (usually two or more were 
present); and at least one other kind of functional 
problem attributed to drug use (usually two or 
more were evident). If an individual's level of 
consumption, number of symptoms, or number of 
problems fell below one threshold value but 
exceeded the other thresholds, a probable need for 
treatment was imputed. If there was at least 
monthly use and some indication of symptoms or 
problems, the individual's need was classified as 
possible. In all other cases, the need for treatment 
was deemed unlikely. 

The committee believes that all of those individuals 
classified as having a clear need for treatment 
exceed the minimum diagnostic criteria for 
dependence. Those with a probable need for 
treatment exceed the criteria for abuse and, in 
some proportion of the cases, for dependence. 
Some of those with a possible need may meet the 
criteria for abuse—most will not. Appendix 3A 
details the procedures used to arrive at these 
estimates. 

On this basis, out of an estimated 14.5 million 
individuals (about 7.3 percent of the household 
population 12 years of age or older) who 
consumed an illicit drug at least once in the month 
before the survey, 4 1.5 million (0.7 percent of the 
population) can be categorized as having a clear 
need for drug treatment at the time of the survey. 
Another 3.1 million individuals (1.6 percent) have 
a probable need; 2.9 million (1.5 percent) have a 
possible need. The other 6.9 million recent 
consumers are unlikely to need drug treatment 
(Figure 3-6). 



"The survey further revealed that an additional 13.5 million 
persons had used an illicit drug in the past year but not in the 
past month and 44.5 million individuals had used an illicit drug 
at least once but not in the past year. 



The clear and probable need cases together 
comprise about 4.6 million individuals, which is 
one-third of the 14.5 million current-month drug 
consumers and about 2.3 percent of the total 1988 
household population of 198 million individuals 
aged 12 and older. The clear and probable cases 
are two-thirds male and heavily concentrated 
among younger adults (aged 18 to 34); youths 
under the age of 18 make up 9 percent of the total 
(about 396,000 persons), and adults 34 years of 
age and older constitute another 16 percent 
(727,000 persons). Most of the adults participate 
in the labor force: 75 percent hold jobs, and 10 
percent are unemployed. The 15 percent not in 
the labor force are primarily in school, retired, 
disabled, or have household responsibilities. The 
unemployment rate among clear and probable need 
cases is about double the 1988 national 
unemployment rate. Although a substantial 
majority of the household residents needing 
treatment maintain jobs in the legitimate economy, 
many have low incomes: 32 percent earn less than 
$9,000 per year, 38 percent earn $9,000 to 
$20,000, and 30 percent earn more than $20,000 
per year. 



Criminal Justice Populations 

Among those groups that may not be well 
represented in the national household surveys are 
the nearly 2 percent of U.S. adults who are under 
the supervision (as inmates, probationers, or 
parolees) of judicial and correctional agencies of 
the federal government, the 50 states, the District 
of Columbia, and the nation's 3,000 counties. The 
sizable proportion of drug treatment clients who 
are also criminal justice clients—far exceeding the 
2 percent share of the general population— indicates 
that the need for treatment among populations 
supervised by the criminal justice system merits a 
separate accounting. Moreover, the number of 
persons under such supervision has been growing 
at a steady rate (5 to 8 percent annually since 
1973) that shows no sign of diminishing. Any 
future growth in the treatment sector, particularly 
on the public side, seems bound to involve an 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



expanded interface with criminal justice 
populations. 



incarceration hardly ensures continued abstinence 
after release. 



On any given day in 1987, the last year for which 
complete counts are available, nearly 3.7 million 
adults were under criminal justice supervision or 
in custody (Allen-Hagen, 1988; Beck et al., 1988; 
Hester, 1988; Kline, 1988; Greenfeld, 1989). A 
minority of this group were serving sentences in 
state and federal prisons (580,000) or county jails 
(140,000) or were in jail awaiting prosecution 
(150,000); three out of four were under 
supervision in the community while on probation 
(2.24 million) or parole (360,000). About 50,000 
minors were in juvenile justice or correctional 
institutions. 

An even larger number of individuals were 
arrested during 1987 and thus came into contact 
with the criminal justice system for short periods. 
There 12.7 million arrests leading to 8.7 million 
jail admissions, 2.6 million arrests were for violent 
or property (income-generating) crimes and 
937,000 were for drug law violations (Jamieson 
and Flanagan, 1989). A large proportion of other 
kinds of arrests (e.g., prostitution, gambling, 
weapons violations, simple assaults) involved drug 
consumers. At any one time, the bulk of these 
arrestees were in the community on bail or on 
recognizance while awaiting disposition of charges. 
The estimates presented in Appendix 3B suggest 
that more than a million of these 1987 arrestees 
clearly or probably needed drug treatment. 
However, there are better data available on 
individuals already under criminal justice 
supervision when arrested or those who come 
under that jurisdiction following arrest and 
disposition of charges. These data fall into two 
categories: those related to individuals in jails or 
prisons and those related to persons under 
community supervision (on probation or parole). 

The prison and jail inmate population numbered 
874,000 at the end of 1987. Inmates are not 
supposed to be consuming drugs while in custody 
(although there is clearly substantial leakage of 
drugs into correctional settings). Many have long 
prior histories of drug abuse or dependence, 
however, and enforced abstinence during 



Prior drug problems are quite common among 
state prison inmates. 5 A 1986 survey of inmates 
(Innes, 1988) found that 80 percent had used an 
illicit drug at least once, 63 percent had used such 
drugs regularly at some time in the past, 43 
percent had used an illicit drug daily in the month 
prior to their offense, and 35 percent were under 
the influence of a drug at the time of the offense. 
State prison inmates typically began illicit drug use 
at age 15, were first arrested at age 17, and first 
began regular use of a "major" drug (heroin, 
cocaine, PCP, LSD [lysergic acid diethylamide], 
methadone) at age 18. The median age of the 
prison population was 28 years. 

Confidential surveys conducted among prisoners 
demonstrate how drug involvement patterns have 
changed both in character and quantity over the 
past 15 years 6 (Table 3-3). In state prisons in 
1974, one in four inmates reported having been 
under the influence of one or more drugs when he 



Regarding prisons versus jails: generally, sentences that will 
involve a minimum of one year actually behind bars are served 
in prisons (state penitentiaries); those with shorter minimum 
confinements are served in county jails. (A few states have a 
single custodial system rather than separate county and state 
facilities.) There are also regular exceptions to this rule. The 
overall length of a sentence is almost always longer (generally 
by a factor of two to three [see Hester, 1988; State Statistical 
Programs Branch, 1989]) than the time to be served in 
custody; the actual amount of time served in prison depends on 
the state's mandatory release policies, the degree of prison 
overcrowding, the convict's behavior while in prison and on 
parole, and other considerations that affect correctional and 
parole policy. 

"Prisoners serve sentences of varying lengths, and those with 
the longest sentences— generally, for murder or rape— constitute 
a much larger share of a prison census than their entering 
numbers would suggest. Because of the length of sentences, 
a prison population, in reporting on pre-arrest drug patterns, is 
like a series of sedimentary layers that reflect criminal drug 
involvement in earlier periods. The pattern is complicated by 
the fact that many prison admissions are returned parole 
violators. At the end of 1988, about 43 percent of state 
prisoners had been newly admitted during the year, 18 percent 
had been returned during the year on parole revocations (about 
half of these with new sentences on top of the old ones), and 
39 percent had been continuously in prison for a year or longer 
(Lawrence Greenfeld, Bureau of Justice Statistics, personal 
communication, July 1989). 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 



(or she, although 19 out of 20 inmates were male) 
committed the crime that prompted his 
incarceration. Heroin was the principal drug 
mentioned; marijuana was less common, and 
cocaine was rare. In 1979, with a third more 
prisoners in custody altogether, one in three 
prisoners had been under the influence of a drug. 
Heroin, however, was mentioned less frequently 
and thus was much lower in proportion and 
numbers. Marijuana had risen substantially on 
both counts, and cocaine prevalence had risen 
dramatically, although it was still less common 
than heroin. 

In 1986, with two-and-a-half times as many 
prisoners in custody as in 1974, the number of 
heroin mentions had increased and was again 
comparable to 1974, although the proportion had 
not kept pace with the overall increase in the 
prison population. Cocaine prevalence now 
exceeded heroin by a large margin, and the 
marijuana figures continued to increase at a pace 
slightly ahead of the increase in all offenders 
imprisoned. 

Based on questions about drug histories, it appears 
that most of those who were under the influence of 
a drug at the time of their offense also stated that 
they had histories of drug dependence and were 
using drugs on a daily basis when the offense 
occurred. The great majority of those who were 
under the influence of drugs were not arrested for 
a drug offense per se (possession, sales, etc.). Of 
all those who reported being under drug influence, 
26 percent were in prison for robbery, 21 percent 
for burglary, 20 percent for a violent crime other 
than robbery, and only 14 percent for a drug 
offense. About the same percentage (42 to 43 
percent) of all those incarcerated for robbery, 
burglary, or drug offenses indicated they were 
under the influence of a drug when the offense 
occurred; about 30 percent of all other imprisoned 
offenders reported drug influence as well. 

Judged according to criteria similar to those 
applied to the household population, prisoners who 
were daily drug users at the time of their offense 
are considered to need treatment; in fact, all of 
them probably meet the diagnostic criteria for drug 
dependence. This group comprised 43 percent of 



all inmates responding to the 1986 state prison 
survey. Applying this finding to the 1987 state 
and federal 7 prison census of 584,000 (Greenfeld, 
1989) results in about 250,000 inmates who need 
treatment. Taking a similar proportion of 
convicted inmates serving time in county jails 
(0.43 x 140,000 ~ 60,000) and juveniles in long- 
term custody institutions (0.43 x 25,000 ~ 
10,000) yields an overall daily estimate of 320,000 
individuals in correctional institutions who need 
treatment. 

At the end of 1987, probation and parole offices 
were supervising 2.6 million unincarcerated 
persons. The mix of offenses among parolees 
closely approximated that of the prison population 
from which they were drawn (and to which, in a 
large proportion of cases, they return following 
parole violations). An estimate that 43 percent of 
parolees (150,000) need drug treatment is therefore 
readily made. 

The much larger probation population is the least 
well studied of all the criminal justice populations 
and consequently offers the most difficulty in 
accurately estimating treatment needs. For one 
thing, it includes a high proportion of less serious 
(nonfelony) offenses. But in general, one would 
expect there to be a significant number of 
probationers with drug problems. The prison- and 
parole-based figure of 43 percent would seem to 
be an upper bound; the estimate (see Appendix 3B) 
that 10 percent of all arrestees need drug treatment 
provides a lower bound. The midpoint of these 
two boundaries, 26 percent, represents about 
580,000 probationers. Combining this figure with 
that for parolees (150,000) produces an estimate of 
approximately 730,000 individuals in the 
community under supervision of the criminal 
justice system who need treatment for drug 
problems. 



'The federal prison population is around 50,000. These 
institutions were not surveyed with the state prisons, but at 
least the same proportion of these prisoners as of the state 
prison populations may be assumed to need treatment. (More 
than two-thirds of those confined in federal prisons are 
sentenced for property or violent crimes . In state prisons these 
offenders have the highest reported drug use, including one- 
quarter of the total who are serving time for drug offenses.) 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



TABLE 3.3 Trends in Numbers and Percentages of Prison Inmates Who Reported 
Being Under the Influence of One or More Drugs at the Time of the Convicted Offense 





1974 




1979 




1986 




Inmate 














Drug 














Status 


No. 


% 


No. 


% 


No. 


% 


No drug 


163,000 


74.7 


204,000 


67.7 


338,000 


64.6 


Any Drug 


55,000 


25.3 


97,000 


32.3 


185,000 


35.4 


Heroin 


35,000 


16.2 


26,000 


8.7 


36,000 


7.0 


Cocaine 


2,000 


1.0 


1 4,000 


4.6 


56,000 


10.7 


Marijuana 


22,000 


10.3 


53,000 


17.6 


97,000 


18.6 



Total 218,000 100.0 301,000 100.0 523,000 100.0 



Sources: Innes (1988); Flanagan and Jamieson (1988). 



62 NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 



TABLE 3-4 Estimated Need for Drug Treatment (in thousands) Among Surveyed 
Adult and Adolescent Populations, 1987-1988 



Those Who 
Population Total Need Treatment 



Household 198,000 

Clear need 1 ,500 

Probable need 3,100 

Homeless (sheltered, 

street, and transient) 1,225 170 

Criminal justice clients 

Correctional custody 925 320 

Probation and parole 2,600 730 

Pregnancy (live births) 3,875 105 

(Less overlaps)" (-470) 

Total needing treatment 5,455 



"In theory, the need for treatment among parolees and probationers should be counted in the household surveys because it is generally 
a condition of parole and probation that certain signs of social stability, such as a fixed address in the community, be maintained. 
However, enforcement of such conditions is spotty. The efficiency of coverage of parolees and probationers in the national drug abuse 
household survey has not been examined. It would be simple to do so, however, by asking respondents whether they were currently 
on probation or parole. Such an hem should be no more subject to nonresponse or validity problems than questions about illicit drugs. 
In the 1 988 national survey on drug abuse, at least 70 of 5,800 adult respondents (Including oversampled subgroups), would have been 
on probation or under parole supervision In the event of standard demographic likelihoods of participation. 

There is some basis for estimating the efficiency of sampling probationers and parolees in the household survey. Criminal recidivism 
among parolees Is very high; around two-thirds of all parolees are rearrested within a few years, and the figure is higher for those needing 
treatment. On this evidence, parolees have much reason to conceal themselves and are not likely to be residentially stable or accessible 
enough for complete enumeration and good representation in a household survey. The committee estimates that only 30 percent of those 
needing treatment, or 45,000 persons, are represented. About 20 percent of all probationers do not successfully complete probation. 
Those needing treatment clearly fail at a higher rate, probably 40 to 50 percent (see, e.g., Toborg and Kirby, 1 984). This recidivism rate 
Is not as high as for parolees, but it does suggest a reduced likelihood of being identified for participation In a household survey. The 
committee estimates that 50 percent, or 270,000 probationers needing treatment, may be represented there. 

Overlap with the homeless estimate seems to require reasoning in the other direction. No data were located on rates of probation or 
parole status among the homeless. Yet the incidence of such status in this group seems likely to be higher than among the residentially 
stable. With the latter proportion placed at about 1 5 percent, doubling that yields 30 percent of the homeless drug-dependent or drug- 
abusing individuals on parole or probotion-50,000 individuals. 

The overlap of women who are pregnant (and give birth to live babies) with the household and other population figures is virtually total. 
The overlap of pregnancy, probation, and parole groups with homeless and household populations needing treatment is thus estimated 
at 470,000. 

Sources: Institute of Medicine analysis of data from the National Household Survey on Drug Abuse conducted by the Research Triangle 
Institute; Innes (1988); Flanagan and Jamieson (1988); Greenfeld (1989); Institute of Medicine (1988b). 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 63 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1, CHAPTER 3 



TABLE 3-5 Approximate Societal Costs (in billions of dollars) of the Drug Problem 

Category Cost 

Victims of drug-related crime (1986) 

Lost work time 1 .5 

Stolen property 2.6 

Lost lives/earnings 1 .2 

Property repairs, medical care 0.2 

Total 5.5 

Crime control resources 

Federal anti-drug (1988) 2.5 
State and local drug law 

enforcement (1986) 3.8 
State and local drug offense 

adjudication, corrections (1986) 2.0 
State and local crime control costs 

from drug-related crimes (1985) 4.5 

Total 12.8 

Criminal careers-lost productivity (1986) 17.6 

Employee productivity losses (1983) 33.3 

Drug-related AIDS ( 1 985) 1 .0 

Drug treatment and prevention (1987) 1 .7 



Source: Institute of Medicine analysis of victimization costs using the methods described in Harwood and coworkers (1 984; cf . Harwood 
et al.. 1988). The figures for criminal victimization in 1986 are taken from Shim and DeBerry (1988). See Appendix 3C for additional 
description of sources. 



64 NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 



The Homeless Population 

Recent studies have estimated that from 200,000 to 
700,000 people in the United States are homeless 
on any given night and as many as 2 million 
experience homelessness at some point during a 
year, staying temporarily in the intervals with 
family, friends, or acquaintances. About three- 
quarters of all homeless people are unattached 
adults; the balance are mostly women with 
children. There is evidence that the homeless 
suffer from a high prevalence of drug disorders; 
several recent studies have found prevalence rates 
of 10 to 33.5 percent, with a median value of 20 
percent (Institute of Medicine, 1988b). 

The homeless are by definition excluded from 
household population studies, as are individuals or 
families who are temporarily staying in someone 
else's household. The need for treatment in this 
otherwise unrepresented population could thus 
range from a minimum of 20,000 (10 percent of 
200,000) to a maximum of 670,000 (33.5 percent 
of 2 million). For its estimate, the committee 
applied the median prevalence value of 20 percent 
of individuals having drug disorders to the 
midpoint one-night homelessness estimate of 
450,000; however, it applied the lower prevalence 
estimate of 10 percent to an additional 775,000 
"hidden homeless" or nonchronically transient (the 
midpoint of the difference between 2 million and 
450,000). Adding the two prevalence figures 
yields a treatment-needing homeless population of 
about 170,000. 



Pregnant Women 

Pregnant women who are consuming illegal drugs, 
especially those with high rates of consumption, 
are of special epidemiological concern. Fetuses 
are vulnerable to maternal consumption of drugs 
during pregnancy, and there has been great 
concern about potentially serious consequences of 
maternal cocaine abuse and dependence for unborn 
babies in terms of premature delivery, small size 
at term birth, developmental somatic defects, and 
impacts on cognitive and behavioral development 



(Chavez et al., 1989; Zuckerman et al., 1989; 
Chasnoff et al., 1990). These risks from cocaine 
abuse or dependence appear comparable to the 
serious risks posed by tobacco or alcohol 
dependence. It is likely that the greater the 
severity of maternal abuse or dependence, the 
greater the risk of fetal damage from the 
pharmacological effects of the drug consumption 
itself and the greater the likelihood of maternal 
complications such as infection (most tragically, 
infection with the human immunodeficiency virus 
[HIV], which causes AIDS), malnutrition, and 
trauma. 

The risks to children of drug-abusing or dependent 
mothers do not necessarily stop accumulating at 
birth. If maternal drug abuse or dependence 
continues, the future of these babies is further 
compromised or threatened on a day-to-day basis 
unless competent and loving care-giving by 
someone else can be arranged— often not an easy 
matter. The best alternative, therefore, is for the 
pregnant and postpartum mother to abstain from 
drug taking, and treatment may be an appropriate 
means toward this end. 

The 1988 RTI/NIDA national household survey 
indicated that about 9.3 million women in high- 
fertility age brackets (15 to 35 years) used an illicit 
drug at least once in the previous year; 4.9 million 
did so within the past month. The overall 
expected birth rate for a group in this age bracket 
would be about 9 percent annually, with 7 percent 
pregnant in a given month. These numbers imply 
a probable range of 350,000 to 625,000 annual 
fetal exposures to one or more episodes of illicit 
maternal drug consumption. Of course, estimates 
of potential maternal drug exposure expressed as 
annual or monthly prevalence rates are not 
especially informative concerning the scope of 
risks of such fetal effects as low birthweight; more 
drug-specific, frequency-specific, and recency- 
specific analyses are needed for these 
determinations (cf. Zuckerman et al., 1989; Petitti 
and Coleman, 1990). 

In terms of the classification methods used in this 
chapter, about 10 percent of all past-month users 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



clearly need treatment (i.e., are dependent), and 
another 20 percent probably need treatment (most 
are classifiable as drug abusers). This implies that 
about 105,000 pregnant women annually are in 
need of drug treatment, based on the same 
diagnostic criteria applied to the general 
population. These statistical estimates assume that 
women who consume illicit drugs are on average 
just as likely as non-drug-taking age peers to give 
birth. No published studies shed direct light on 
this assumption, which may be too generous, 
considering that birth rates are much higher among 
married versus unmarried women and that married 
women are a much more abstemious group; on the 
other hand, it may not be generous enough, given 
that drug consumers, at least among teenagers, are 
more sexually active and more often pregnant than 
abstainers. At any rate, the estimate of 105,000 
pregnant women needing drug treatment annually 
is a subset rather than addition to the estimated 
numbers in need of treatment noted in previous 
sections. 8 



Summary 

The committee's combined estimate of the point- 
in-time need for treatment on a typical day in 
1987/1988 is approximately 5.5 million individuals 
(Table 3-4). This number includes about 1 in 50 
household residents older than 12 years of age, 
more than one-third of all prison and jail inmates, 
and more than one-fourth of all parolees and 
probationers. The total estimate is about 2.7 
percent of the U.S. population aged 12 years or 
older. 



Working from a different base—studies among obstetrical 
patients-Chasnoff and associates have estimated that about 
375,000 babies in the United States (more than 10 percent of 
live births) may be exposed annually to illicit drugs. This figure 
is within the committee's estimated range, although it is based 
on samples of uncertain representativeness that use a variety 
of methods. The major study (Chasnoff, 1989) involves 36 
hospitals across the country. Nearly all of them are urban core 
medical centers serving large proportions of the innercity poor, 
who are likely to display illicit drug prevalence rates well in 
excess of the national average. In another study by Chasnoff 
and coworkers (1990), however, which covers a highly 
urbanized county in Florida, these investigators found rates of 
positive drug tests among prenatal clinic patients that 
approached those in some central cities, even among cases 
observed in private obstetrical practices. 



In finer grain, the survey data indicate that about 
1.5 million persons in the household population 
clearly need treatment; the committee believes this 
to be a minimum estimate of the prevalence of 
drug dependence in that group. The survey 
questions used to estimate treatment needs in the 
criminal justice population are simpler and cruder 
than those used in the household survey. The 
criteria provided by these survey items are much 
more like the "clear" (that is, more severely 
impaired) than the "probable" householder 
treatment criteria; in other words, the individuals 
meeting these criteria (daily-user criminals) are 
likely to be drug dependent rather than drug 
abusing. Considering the overlap in estimates, the 
committee therefore judges that at least 1.3 million 
household residents who are not currently under 
criminal justice supervision need treatment for 
drug dependence; 1 . 1 million individuals who are 
under justice supervision also need such treatment 
(one-third of these individuals are currently in jail 
or prison). About 3 million additional household 
residents probably need treatment; most of them 
would be diagnosed with the less severe condition 
of drug abuse. Another 100,000 homeless 
individuals who are not under criminal justice 
supervision also need treatment for dependence or 
abuse. 



QUANTIFYING 
THE CONSEQUENCES 



As a final component in considering the need for 
treatment, it is important to analyze the adverse 
effects—the burden—of drug abuse and dependence. 
In particular, to gauge the extent of this burden, it 
is important to use the same scale of measurement 
as that usually used to address the problem, 
namely, monetary cost. This approach, of course, 
is strictly economic and is not the ultimate measure 
of policy: in particular, the moral and emotional 
dimensions of the drug problem are virtually 
impossible to calibrate in monetary terms. But 
there is value in signaling the overall economic 
consequences of drug abuse and dependence, and 
this approach is a precursor to cost-effectiveness 
and cost/benefit studies that more closely assess 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREA TMENT 



the economic payoffs and merits of alternative 
responses and strategies (cf. Grant et al., 1983). 

Most studies of the cost or burden of drug abuse 
(A. D. Little Co., 1974; Lemkau et al., 1974; 
Rufener et al., 1977b; Craze et al., 1981; 
Harwood et al., 1984) have used a "human 
capital" approach, which has become fairly 
standard in estimating the costs of health problems 
(Rice, 1966; Cooper and Rice, 1976; Hodgson and 
Meiners, 1979). This method is conservative in 
that it measures only those dimensions of a 
problem that can be expressed as tangible losses 
from the stock of potentially productive labor and 
property in society. In so doing, it ignores the 
possibility that the actual or potential loss victims, 
as a group, might be willing to pay more to avoid 
these losses than the equivalent tangible costs 
alone. In other words, the pain, suffering, fear, 
and demoralization that accompany the tangible 
losses reflected in economic measures of drag 
problems are not fully accounted for by the human 
capital approach. There is also as yet no good 
analytical basis for quantifying the downstream 
costs of neurologic and other deficits of drag- 
dependent infants or the neglect and abuse of 
children by drag-impaired parents. 

The last thorough estimate of the societal cost of 
drag problems, which covered 1983, was 
published several years ago (Harwood et al., 
1984). Since then, a number of statistical updates 
and revisions have become available. The 
committee's more contemporary estimate, based on 
the most recently published data, is presented in 
Table 3-5. 

The costs are of several types. The criminal 
aspect of drag use accounts for more than half of 
the amount estimated here: $5.5 billion worth of 
tangible losses to victims of property and violent 
crimes, $12.8 billion in enforcement costs, and 
$17.6 billion in productivity lost to legitimate 
economic enterprises because of time spent instead 
in prison or in criminal enterprises. Nearly equal 
in magnitude to the sum of these crime-related 
costs were the estimated reductions in the 
productivity of employees whose work 



performance was impaired by drag consumption. 
The health costs of drag problems in relation to 
AIDS and expenditures for drag treatment and 
prevention programs are other, not insubstantial 
costs, but they are much smaller than the costs 
incurred as a result of drag-related crime. Further 
details concerning the generation of estimates in 
Table 3-5 are provided in Appendix 3C. More 
elaborate new estimation analyses are currently 
being prepared by Dorothy Rice and colleagues for 
NIDA, referenced to index year 1985 (cf. Rice and 
Kelman, 1989), and by the Research Triangle 
Institute for the Bureau of Justice Statistics; neither 
set of results is yet available. 

These cost estimates cannot be quantitatively 
disaggregated to show costs for drag use, abuse, 
and dependence, although it is certain that drag 
use as such is a small direct contributor to these 
costs. However, the roughly even division 
between crime-related losses and employment 
losses bears a rough correspondence to the 
estimate made above: those persons who are most 
clearly in need of treatment for dependence are 
almost evenly divided between the pool of several 
million criminal justice clients and the much larger 
base population, the source of the nation's regular 
labor force. 



CONCLUSION 



Few if any problems in American society are as 
complicated or as mutable as the issue of drag use, 
which has been one impetus for the proliferation of 
policy ideas and instruments. Because drag 
treatment is only one of several accepted policy 
instruments, the dominant question is how to 
calibrate its role— to determine how much treatment 
is needed, by whom, of what kinds, for how long, 
and at whose cost. In trying to make these kinds 
of policy decisions, particularly for the future, 
there are three important implications of the 
problem's complexity. 

The first implication, which is elaborated in this 
chapter, is that careful methods and sophisticated 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



knowledge are required to grasp the nature and 
quantify the extent of the need for treatment. A 
clear understanding of this aspect of the problem 
is particularly important when concepts such as 
"treatment on demand" or "required coverage" 
become the focus of debate. Those who are 
expected to underwrite the costs reflected by these 
concepts justifiably worry about stepping into a 
murky and bottomless pit of financial obligation. 
The need for treatment is great and probably still 
expanding, but the pit does have a bottom, and the 
murk can be cleared. Measures of the raw 
prevalence of drug taking— usually expressed in 
such terms as the 28 million Americans who took 
an illegal drug one or more times in the past year- 
are not good gauges of the extent of the need for 
treatment. Current prevalence statistics measure 
the pool of drug involvement for which some type 
of response— but not necessarily treatment— may be 
needed. The extent of the need for treatment 
becomes clearer if one focuses on two particular 
features that simultaneously have biological, 
psychological, and social significance: the level 
and pattern of consumption behavior, and the 
number and severity of functional problems an 
individual is experiencing or causing as a result of 
this behavior. 

The overall prevalence of drug use is a poor 
absolute measure and an imperfect correlate of the 
extent and severity of problems, probably because 
different subgroups of the population have 
different trajectories of drug involvement. 
Although the number of users— that is, lighter 
consumers— may dip or soar over the short term, 
heavy consumers usually require some time to 
reach that level and are slower to change. Even 
good information about the distribution of drug 
consumption across the population leaves a margin 
of uncertainty about the need for treatment because 
a few individuals can consume heavily or regularly 
with seeming impunity while others have severe 
trouble at much lower doses and frequencies. 
These differences have much to do with the kind 
of social advantages and supports available to the 
individual. 



drug consumption and consequences: from 
abstinence through use, abuse, and dependence, 
and on to recovery and relapse. The two 
outstanding points about this model are the specific 
identification of a need for treatment with drug 
abuse and (especially) dependence, and the 
recognition that individuals continually move into 
and out of these conditions. The factors that 
propel individuals through the stages of this model 
are mainly learning and conditioning processes, 
which are strongly shaped by the economic, social, 
and cultural dimensions of a person's environment. 

Drug abuse and dependence are distinguished from 
drug use through diagnostic criteria; in turn, these 
criteria, when applied to sample surveys of the 
population, permit moderately accurate estimates 
of the aggregate need for treatment. The 
committee analyzed a number of surveys of the 
general and special populations that contained 
questions similar to the diagnostic criteria and 
arrived at a new estimate of about 5.5 million 
people who need drug treatment (slightly more 
than 2.5 percent of the overall adolescent and adult 
U.S. population of more than 200 million people). 
It is estimated that about 1.1 million of these 
individuals are dependent on drugs and are clients 
of the criminal justice system; another 1.4 million 
are dependent but not under justice system 
supervision; and the other 3 million individuals are 
drug abusers in the household population who 
probably need less treatment both in terms of 
quantity and intensity. 

The above breakdown leads directly to the second 
implication of the complex nature of the drug 
problem: different forms of treatment are needed. 
A wide variety of specific drug problems (some of 
which are in fact psychosocial or health problems) 
may precede drug abuse or dependence and exist 
apart from them; nevertheless, such problems 
contribute to drug-seeking behavior and affect 
opportunities for recovery and the chances of 
relapse. Many of these issues come to a head in 
selecting or negotiating the goals of treatment, 
which are the principal subject of Chapter 4. 



This chapter outlines an analytical model to 
distinguish different types and stages of individual 



The third implication of the complexity of the 
problem of drug consumption is that evaluating the 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 



costs and benefits of treatment is a very demanding 
task. The course of drug problems is diverse and 
full of branching probabilities, and it seems to be 
affected by many things about which scientific 
knowledge is still quite limited. Even though a 
single intervention may have little effect on an 
individual at the time it is delivered, the effects of 
serial interventions may accumulate significantly 
over a period of time. Determining how treatment 
affects the course of drug problems— what its 
incremental benefits may be— requires sophisticated 
analysis; considering current data limitations and 
analytical capabilities, such analyses cannot escape 
uncertainties. 

These uncertainties might be greatly reduced in the 
event of a miracle cure for drug dependence. But 
none exists as yet, nor is such a cure a prospect 
for the immediate future. As with heart disease 
and cancer in the health domain, theft and 
assaultive behavior in the realm of crime, or 
homelessness and family dissolution in the area of 
social welfare, even the best interventions work 
only partially— some of the time and for some of 
the people. In none of these cases does the 
absence of a panacea excuse society from 
responding to the best of its ability or from 
working to find and improve the best ideas (even 
if they are only partially successful). The costs of 
drug problems are so high that reducing them even 
modestly is worthwhile. The complexity, 
uncertainty, and costs associated with drug abuse 
and dependence, as noted in this chapter, 
undergird the analysis of treatment effectiveness 
and costs and benefits in Chapter 5. 



APPENDIX 3A 

ESTIMATING THE NEED FOR 

TREATMENT IN THE HOUSEHOLD 

POPULATION 



Previous estimates using the national household 
surveys were based on the frequency of drug 
consumption only. Yet the diagnostic algorithms 
developed in DSM-III-R, ICD-10, and their 
predecessors refer to physiological and 
psychological symptoms of dependence and abuse 
and to psychosocial problems and consequences of 
consumption. These may be correlated with 
consumption frequency, but they are not simply 
isomorphic with frequency. 

The household survey instrument does not directly 
employ all of the DSM or ICD criteria (see Table 
3-2), but it includes numerous items that are very 
similar to them. The survey inquires about the 
current frequency of illicit drug consumption (days 
of use in the past month), symptoms of 
dependence in the past year, and problems and 
consequences of drug use in the past year. In this 
analysis, frequency of drug consumption was 
coded into eight ranges: 

■ no current illicit use of any drug; 

■ current use of unknown intensity; 
[Most frequent use of any one drug in 
the past month:] 

■ once; 

■ 2 to 4 times; 

■ 5 to 8 times; 

, ■ 9 to 16 times; 

■ 17 to 24 times; and 

■ 25 to 30 times. 

The symptoms of dependence were coded into 
three ranges: no reported symptoms from any 
drug; one reported symptom from any drug; and 
two or more symptoms from any drug. The 
survey questions used to elicit information on 
dependence were as follows: 

In the past year: 



Special analyses of the 1988 National Household 
Survey of Drug Abuse were conducted to Institute 
of Medicine (IOM) specifications at the Research 
Triangle Institute to quantify the need for drug 
abuse treatment among the household population. 



Have you ever tried to cut down on your use of 
any of these drugs? 

Circle the number next to each drug for which 
you have ever needed larger amounts to get the 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



same effect or that you could no longer get 
high on the amount you used to use. 

Circle the number next to each drug you have 
ever used each day or almost daily for two or 
more weeks in a row. 

Circle the number of each drug you felt that 
you needed or were dependent on. 

Circle the number next to each drug for which 
you 've had withdrawal symptoms, that is, you 
felt sick because you stopped or cut down on 
your use of it. 

Response categories for each of the above: 
cigarettes; alcohol; sedatives; tranquilizers; 
stimulants; analgesics; marijuana; inhalants; 
cocaine; hallucinogens; heroin; other opiates, 
morphine, codeine; never experienced this. 

The problems and consequences of drug use were 
coded into three ranges: no reported problems 
from any drug; one reported consequence from 
any drug; and two or more consequences from any 
drug(s). The questions below were used to elicit 
information on drug problems; the drugs listed 
above (see the questions on dependence) were also 
used as response categories for these questions. 



Have you had any of these problems in the past 12 
months from your use of any of the substances on 
this card? If yes, write in which substances you 
think probably caused the problem. 

Became depressed or lost interest in things. 
Had arguments and fights with family or 

friends. 
Had trouble at school or on the job. 
Drove unsafely. 
At times, I could not remember what happened 

to me. 
Felt completely alone and isolated. 
Felt very nervous and anxious. 
Had health problems. 
Found it difficult to think clearly. 
Had serious money problems. 
Felt irritable and upset. 



Got less work done than usual at school or on 

the job. 
Felt suspicious and distrustful of people. 
Had trouble with the police. 
Skipped four or more regular meals in a row. 
Found it harder to handle my problems. 
Had to get emergency medical help. 

Tabulations of these three variables are reported in 
Table 3A-1 (levels of consumption) and Table 3A- 
2 (cross-tabulations of the symptom and problem 
indexes). Cigarettes and alcohol were excluded 
from the tabulations into categories. The symptom 
and consequence indexes (each with values of 0, 1, 
or 2) were summed to yield a symptom/problem 
scale with values of through 4. Those 
individuals with a value of zero reported neither 
symptoms nor problems in the past year; those 
with a value of 4 experienced at least two 
symptoms and two problems. A value of 2 means 
two or more symptoms with no problems, two or 
more problems with no symptoms, or one of each. 
Similar interpretations apply to the indicator values 
1 and 3. The symptom/problem scale was then 
cross-tabulated with the level of current use. The 
resulting matrix (Figure 3A-1) can be readily 
transformed into relative need for treatment. In an 
ordinal sense, those with the least need would be 
expected to be in the upper left of the matrix (very 
low use, few or no symptoms/problems), whereas 
those with the greatest need would be in the lower 
right corner (highest use, highest 
symptoms/problems) . 

The categories of "clear," "probable," "possible," 
and "unlikely" need for treatment are used to 
indicate the likelihood that the respondent would 
require treatment (Figure 3A-2). "Clear" need is 
defined as a consumption frequency exceeding 
twice weekly and a value of 3 or 4 on the 
problem/symptom scale. More-than-twice- weekly 
consumers with two or fewer symptoms/problems 
are assigned to the "probable" category. Also 
"probable" are those with a maximum use of any 
single drug of from two to eight days per month 
and a scale value of 3 or 4. The frequency index 
measures only the drug that is taken most 
frequently; because many respondents take more 
than one substance, however, an individual may be 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREA TMENT 



taking other drugs less frequently and at different 
times. For relatively infrequent consumers, the 
major clinical sign is clearly the elevated 
symptom/problem count. 

An individual who consumes an illicit drug five to 
eight times a month with a low problem/symptom 
count is classified as having a "possible" need for 
treatment. In the same class are consumption 
levels of two to four episodes per month and a 
scale value of 1 or 2, once-a-month consumption 
with scale values of 3 or 4, and unknown levels of 
use. All other individuals are considered relatively 
"unlikely" to need treatment. 

Out of 14.5 million current-month drug 
consumers, the committee classified 1.5 million as 
clear candidates for treatment, 3.1 million as 
probable, 2.9 million as possible, and 6.9 million 
as unlikely. For purposes of estimating the need 
for treatment in the household population the clear 
and probable groups total 4.6 million. Sex, age, 
labor force participation, and earnings of this 
combined group are reported in Table 3A-3. 

The statistical properties of these estimates 
(standard errors) are complex and have not yet 
been computed. Research Triangle Institute staff 
consider estimates based on fewer than 15 to 20 
case observations to have unacceptably high 
standard errors. Most of the estimated population 
characteristics presented here, however, have more 
than adequate sample cases. (For example, the 
estimate of 4.6 million persons with clear or 
probable need for treatment is based on 247 cases 
meeting the defined criteria.) To provide a sense 
of the likely statistical properties of these 
estimates, 95 percent confidence intervals for past- 
month drug use in subpopulations with estimated 
use by 5 million or fewer individuals are presented 
in Figure 3A-3. Larger population estimates have 
better statistical properties. (Note that the 95 
percent confidence interval is generally smaller, 
relative to the value of the estimate, for larger 
estimates.) Smaller estimates have lower 
reliability. 



The plot demonstrates scatter because various 
subpopulations were sampled at differential rates 
(e.g., youth and Hispanics were sampled at 
relatively higher rates, whereas adults aged 35 and 
older and whites were sampled at lower rates). 
Therefore, identical estimates for two different 
subpopulations can have very different statistical 
properties: an estimate of 500,000 youths needing 
treatment is much more reliable than an identical 
estimate for older adults because the estimate for 
youth is based on about 70 to 80 cases, whereas 
the estimate for adults aged 35 and older is based 
on only 10 to 15 cases. 



APPENDIX 3B 

ESTIMA TING THE NEED FOR 

TREA TMENT AMONG ARRESTEES 



Information about drug use by arrestees is 
collected by the Drug Abuse Forecasting (DUF) 
system created by the National Institute of Justice. 
This program reports on a quarterly basis 
urinalysis results collected from arrestees in a 
dozen or more cities or urban areas ranging in size 
from Indianapolis to Chicago, Manhattan, and Los 
Angeles. Urinalysis can detect opiate or cocaine 
doses (for 48 to 72 hours), marijuana (for 1 to 4 
weeks), and other drugs (for varying lengths of 
time; see Hawks and Chiang, 1986). 

The DUF samples are not random but purposive, 
concentrating on drug charges and violent and 
property crimes according to individual stratified 
sampling schemes in each city. For this reason, 
the DUF results are not directly representative of 
all arrestees nationwide or even in the cities 
represented. For example, about 35 percent of 
DUF sample arrests in mid- 1988 were for drug 
offenses, burglary, and robbery, exceeding the 
percentage of arrests for these charges in 53 U.S. 
cities of comparable size (more than 250,000 
residents) by a factor of about 2.5 and exceeding 
their percentage of all U.S. arrests by about a 
factor of 3 . 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



Drug use is pervasive among DUF arrestees. In 
the most recently reported summary statistics for 
the fall of 1989 (O'Neil et al., 1990), about two- 
thirds of male and female arrestees screened 
positive for at least one drug, ranging from 53 to 
84 percent for men (in San Antonio and New 
York, respectively) and from 42 to 90 percent for 
women (in Indianapolis and Philadelphia). More 
specifically, cocaine traces were found in about 
one-half of the men (28 to 77 percent) and the 
women (22 to 79 percent), marijuana traces were 
found in about one-fourth of the men (13 to 48 
percent) and one-fifth of the women (8 to 27 
percent), and opiates were found in one-tenth of 
the men (2 to 23 percent) and the women (1 to 27 
percent). About one-fourth of the sample were 
positive for more than one illegal drug. 

Additional information is obtained from DUF 
interviews. Arrestees are asked whether they 
consider themselves dependent on drugs, whether 
they could benefit from treatment, or whether they 
are enrolled in treatment. A positive response to 
one of these items, in conjunction with a positive 
drug test, is interpreted as indicating a likely need 
for drug treatment. A positive test but negative 
verbal responses is interpreted as ambiguous 
evidence of need for treatment. Table 3B-1 
indicates findings for early 1988. About 29 
percent of DUF arrestees were classified as likely 
to need treatment, another 48 percent as possibly 
needing treatment (ambiguous results), and the 
final 24 percent as unlikely because they tested 
negative (some of these individuals may 
nonetheless have drug problems that require 
treatment, but they were not detected). Summary 
statistics on need for treatment in the DUF sample 
in early 1989 were published by Wish and O'Neil 
(1989). 

There is some variation in these rates across 
different offense types, as reported in Table 3B-2. 
Probable need for treatment was higher for those 
committing income-generating crimes (robbery, 40 
percent; burglary and larceny, 34 percent) and 
drug offenses (37 percent) than for those 
committing violent crimes (homicide, 16 percent; 
sex offenses, 21 percent; assaults, 25 percent). 



The proportion of arrestees needing drug treatment 
in the DUF cities can be roughly extrapolated to a 
national basis, adjusting for variations in the 
number of high-probable-need offenses (burglary, 
robbery, and drugs) reported in all large cities, 
smaller cities, suburbs, and rural areas. After this 
adjustment, about 700,000 arrestees nationwide 
would be likely to need treatment. If the 
ambiguous cases are added to this estimate, 
another 1.2 million arrestees might need drug 
abuse treatment. The number of individuals 
represented by arrests would likely be 10 to 20 
percent lower owing to multiple arrests per year. 



APPENDIX 3C 

ESTIMATING THE COSTS OF DRUG 

PROBLEMS 



Drug-related Crime— Victim Losses 

There were 34.1 million personal and household 
victimizations in the United States in 1986 (Shim 
and DeBerry, 1988). These crimes cause injury, 
property damage and personal inconvenience worth 
billions of dollars per year, as well as forcibly 
transferring further billions of dollars from victims 
to perpetrators. It is conservatively estimated that 
more than 25 percent of property crime and about 
15 percent of violent crime—a total of 9 million 
crimes— are related to drug abuse by the criminal. 
In other words, without the criminals' current and 
prior involvement with drugs, these crimes would 
not have been committed. 

Using the methods of Harwood and coworkers 
(1984, 1988), victim losses from the drug-related 
crimes have been estimated at $1.7 billion, of 
which the largest proportions were for lost work 
time ($1.5 billion), property damage ($150 
million) and medical care costs ($50 million). 
Further losses experienced by victims were 
attributable to the value of the property stolen, 
which for the 9 million drug-related crimes noted 
above was $2.6 billion. 

Homicide is strongly linked to drug trafficking. 
Surveys of homicide arrestees have found that 



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NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREA TMENT 



more than 50 percent are positive for drugs and 16 
percent claim they are addicted to illicit drugs 
(Innes, 1988). Twenty-eight percent of inmates 
convicted of homicide or nonnegligent 
manslaughter claim to have been under the 
influence of illicit drugs at the time of the crime, 
and 12 percent admit to being daily users of heroin 
or cocaine (Innes, 1988). Conservatively, 
averaging the 12 percent who admit daily use and 
the 16 percent who claim addiction yields a causal 
involvement for drugs in homicide of 14 percent. 
This implies that 2,900 homicide deaths (out of the 
20,600 total estimated by the Bureau of Justice 
Statistics) were drug related. The economic value 
of homicide victims' lost productivity was $1.2 
billion. 



Crime Control Resources 

The federal government spent $2.5 billion on 
criminal justice activities specifically directed 
against the drug trade and drug traffickers in 1988, 
an increase from the $1.76 billion spent in 1986 
(White House Office of Public Affairs, 1988). 
U.S. contributions to efforts to interrupt the 
international drug trade consumed $1.2 billion, 
whereas federal domestic investigations received 
$584 million. Federal prosecutions and 

corrections efforts cost $150 and $560 million, 
respectively. 

Federal drug enforcement efforts have grown from 
$36 million in 1969 to $2.5 billion in 1988, with 
projected 1989 expenditures of $3.8 billion 
(Strategy Council on Drug Abuse, 1975; Office of 
National Drug Control Policy, 1989). State and 
local governments devote even more resources 
specifically to fighting the drug trade. A national 
survey of law enforcement agencies found that, in 
1986, 18.2 percent of total expenditures were for 
this purpose (Godshaw et al., 1987), amounting to 
$3.8 billion out of nearly $21 billion in state and 
local law enforcement (police) efforts. 
Adjudication, legal, and correctional services 
dedicated specifically to fighting the drug trade 
cost a further $2 billion. 



In addition, much violent and property crime is 
believed to be motivated by drug abuse (drug- 
related crime). Using conservative assumptions 
about the causal role of drug abuse in violent and 
property crime (about 15 percent and 25 percent, 
respectively, as discussed above), state and local 
criminal justice efforts against drug-related crime 
probably cost $4.5 billion in 1985. 



Employee Productivity Losses 

The largest economic impact of drug abusers 
derives from their abandoning the legitimate 
economy for the underground one and their 
potentially impaired performance in legitimate 
jobs. These impacts represent losses of potential 
legitimate productivity—services that are never 
delivered to the workplace because the drug 
abusers have entered criminal careers or been 
incarcerated or because they do not perform in 
jobs as well as their non-drug-abusing peers. 
Crime career and incarceration losses to the 
economy were $12.2 and $5.4 billion in 1986, 
which arise from significant commitments to crime 
career endeavors by 1.1 million persons and the 
incarceration of 200,000 persons on drug charges 
or drug-related offenses (updated estimates from 
Cruze et al., 1981, and Harwood et al., 1984). 

Reduced productivity among those in the work 
force is the most complicated calculation; it may 
also be the largest burden resulting from drug 
abuse. Harwood and colleagues (1984) estimated 
that in 1983 nearly 8 million persons had severe 
prior histories of drug use (daily consumption of 
marijuana or other illicit drugs for a minimum of 
a month at some time in life) that were 
significantly related to their having a lower 
household income than their peers. The losses of 
legitimate potential productivity so estimated were 
$33.3 billion in 1983. The lost income 
represented by this cost directly affects the well- 
being of drug-involved individuals and their family 
members, who may be doubly afflicted (as may the 
drug abusers themselves) because of theft and 
partial or total reliance on social welfare. Failure 
to earn a legitimate income affects public revenues 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 

through losses in tax contributions on earnings and 
expenditures. These costs are thus spread in 
various ways (that are difficult to quantify) from 
the individual to society. 

Health Costs 

Most drug treatment and prevention services are 
government supported, but there is also significant 
private payment for treatment. These services 
have received an enormous boost since the 1986 
Anti-Drug Abuse Act, with the federal 
commitment escalating markedly in 1987, 1988, 
and 1989. Expenditures for drug treatment were 
at least $1.3 billion in 1987 (see Chapter 6); 
prevention activities (which target both drugs and 
alcohol) were $212 million in 1987 (Butynski and 
Canova, 1988). Drug abuse-related AIDS costs in 
1985 were estimated to be $967 million (Rice et 
al., 1990). About 25 percent of all AIDS cases to 
date have a history of intravenous drug abuse 
(Institute of Medicine/National Academy of 
Sciences, 1988), a figure that represents a steady 
rise throughout the 1980s (Miller et al., 1990). 



74 NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



THE NEED FOR TREATMENT 

TABLE 3A-1 Frequency of Illicit Drug Consumption (for one month) and Estimated 
Prevalence by Level of Consumption 

Level Sample Estimated 

of Consumption" Cases Prevalence 



Unknown 215 3,744,840 

1 141 2,363,026 

2-4 192 3,152,013 

5-8 79 1,296,743 

9-16 82 1,727,539 

17-24 55 987,827 

25+ 63 1,206,790 

Total 827 14,478,778 



'Number of times drugs were used in previous month. 

Source: Institute of Medicine analysis of data from the 1 988 National Household Survey on Drug Abuse, performed by Research Triangle 
Institute for the National Institute on Drug Abuse. 



TABLE 3A-2 Estimated Number (in thousands) and Percentage of Current Drug Users 
Who Experienced Negative Consequences of Drug Use and Symptoms of Dependence 
During the Past Year (1988) 







Negative 


Consequences of Drug Use 




Total 








None 




1 




2 + 






Symptoms of 




















Sample 


Dependence 


No. 


% 


No. 




% 


No. 


% 


No. 


% 


Cases 


None 


5,734 


39.6 


381 




2.6 


261 


1.8 


6,376 


44.0 


367 


1 


2,366 


16.3 


320 




2.2 


273 


1.9 


2,959 


20.4 


172 


2 + 


2,669 


18.4 


489 




3.4 


1,986 


13.7 


5,144 


35.5 


288 


Total 


10,769 


74.4 


1,190 




8.2 


2,520 


17.4 


14,479 


100.0 


827 


Sample Cases 


603 




70 






154 




827 







Source: Institute of Medicine analysis of data from the 1 988 National Household Survey on Drug Abuse, performed by Research Triangle 
Institute for the National Institute on Drug Abuse. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 75 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1. CHAPTER 3 



TABLE 3A-3 Need for Treatment (clear plus probable) in the Household Population by 
Gender, Age, Labor Force Status, and Earnings, 1988 



Characteristic 



Sample 
Cases 



Estimated 
Prevalence 



Percentage 



Gender 



Male 
Female 
Subtotal 



154 


3,169,412 


68.4 


93 


1,463,103 


31.6 


247 


4,632,515 


100.0 



Age 



12-17 years 
18-25 
26-34 
35 and over 
Subtotal 



58 


395,736 


8.8 


84 


1,882,855 


41.8 


73 


1,501,764 


33.3 


19 


726,788 


16.1 


234 


4,507,143 


100.0 



Labor force status of adults (aged 18 and older) 



Employed 
Unemployed 
Not participating 
Subtotal 



Unemployment rate 



125 


3,108,314 


75.6 


19 


389,174 


9.5 


32 


613,919 


14.9 


176 


4,111,407 


100.0 


144 


3,497,488 


11.1 



Earnings of adults (those employed) 



Less than $9,000/year 
$9,000-20,000/year 
Over $20,000/year 
Subtotal 



38 

50 

37 

125 



1 ,000,047 

1,187,341 

920,926 

3,108,314 



32.2 

38.2 

29.6 

100.0 



Total 



247 



4,632,515 



100.0 



Source: Institute of Medicine analysis of data from the 1 988 National Household Survey on Drug Abuse, performed by Research Triangle 
Institute for the National Institute on Drug Abuse. 



76 



NIDA ABUSE SERVICES RESEARCH SERIES. No. 2 



THE NEED FOR TREATMENT 



100 r 



75 - 



111 

O 50 

HI 
Q. 



25 - 



• * * 


. 4 

• 


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1 9 


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i i 


1 1 



mini 2' 




Symptom/Problem 
Scale 



Year N.R. 1 2-4 5-8 9-16 17-24 25+ 
DAYS OF USE IN PAST MONTH 



FIGURE 3A-1 Problems by frequency of drug use in the household population, 1988. 
Year = no use in past month but at least once in the past year; 
N.R. = no response on frequency of items. 

Source: Institute of Medicine analysis of date from the 1 988 National Household Survey on Drug Abuse, performed by Research Triangle 
Institute for the National Institute on Drug Abuse. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



77 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1. CHAPTER 3 



UJ 
O 

z 

Lii 

o 

CO 
LLI 
Q_ 



100 

90 
80 
70 
60 
50 
40 
30 
20 
10 




19: 



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: *< 
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62 



r°'1 Unlikely 
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v° 



^ ^ ^ 

• * 



FIGURE 3A-2 Need for treatment by frequency of use in the household population, 1988. 

Source: Institute of Medicine analysis of data from the 1 988 National Household Survey on Drug Abuse, performed by Research Triangle 
Institute for the National Institute on Drug Abuse. 



78 



NIDA ABUSE SERVICES RESEARCH SERIES. No. 2 



THE NEED FOR TREATMENT 



II 

lufc 

O 111 

1ft 

o< 



2.6 
2.4 
2.2 

2 
1.8 

1.6 
1.4 

1.2 
1 
0.8 
0.6 
0.4 
0.2 





mrmnrm m rmrffl rrm rviwnnrhrt ^ fl 3 3 flj QdlD Qp 




95% Lower 



12 3 4 

ESTIMATES OF CURRENT DRUG USE (in millions) 



FIGURE 3A-3 Confidence interval of estimates of current illicit drug use by subpopulations. The 
estimates indicate the illicit use of drugs during any past month for subpopulations (combinations of 
age. sex. race, and region) with fewer than 5 million users. The reported 95 percent confidence 
intervals are divided by the estimates to produce ratios. 

Source: National Institute on Drug Abuse (1989). 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



79 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 3 



TABLE 3B-1 Arrestees' Potential Need for Treatment (percentage of total cases) by 
City, Spring 1988, based on Drug Use Forecasting Data 



Potential Need for Treatment 



City 



Total 

New York 

Portland 

Indianapolis 

Houston 

Detroit 

New Orleans 

Phoenix 

Chicago 

Los Angeles 

Other 



Probable 


Ambiguous 


Unlikely 


Cases 


29.0 


47.5 


23.6 


2,428 


51.0 


39.7 


9.3 


257 


26.6 


51.3 


22.1 


263 


32.3 


26.9 


40.8 


130 


11.3 


58.8 


29.9 


204 


29.9 


41.9 


28.1 


167 


15.2 


60.7 


24.1 


191 


21.9 


46.2 


31.9 


251 


29.3 


52.7 


18.0 


283 


41.0 


39.9 


20.0 


446 


15.7 


56.6 


26.7 


236 



Source: Unpublished Drug Use Forecasting system statistics provided by Dr. Eric Wish, National Institute of Justice. 



TABLE 3B-2 Arrestees' Potential Need for Treatment (percentage of total cases) by 
Charge at Arrest, Spring 1988, based on Drug Use Forecasting Data 





Potentic 


il Need for Treatment 




Charge 


Probable 


Ambiguous 


Unlikely 


Cases 


Total 


29.0 


47.5 


23.6 


2,428 


Assault 


25.4 


42.0 


32.6 


264 


Burglary 


33.6 


52.2 


14.2 


247 


Drug sale/possession 


36.6 


54.8 


8.6 


465 


Weapons 


18.6 


50.0 


31.4 


70 


Homicide/manslaughter 


16.2 


40.5 


43.2 


37 


Robbery 


40.0 


41.8 


18.2 


165 


Stolen property/vehicles 


25.0 


52.8 


22.2 


176 


Sex offenses 


20.9 


38.4 


40.7 


86 


Larceny/pickpocketing 


34.1 


41.1 


24.7 


287 


Other 


21.3 


47.0 


31.7 


624 



80 



NIDA ABUSE SERVICES RESEARCH SERIES. No. 2 



CHAPTER 4: DEFINING THE GOALS OF TREATMENT 



A wide range of hopes have been fastened on drug 
treatment, in keeping with the diversity among 
those who take a strong interest in treatment 
programs: clients, their families, clinicians, 
outside payers, employers, and public agencies. 
How these different expectations can be reconciled 
and prioritized is a fundamental question- 
particularly for the development of measures to 
assess treatment outcome. Such assessments are in 
turn crucial at a time when competition for 
budgetary dollars is intense and health cost control 
measures are targeting substance abuse benefits for 
differential reductions— even though the public and 
the President rank the drug problem above national 
security and economic concerns as the country's 
most serious current issue (Gallup, 1989; Bush, 
1990). 

Every treatment program needs to have operational 
goals, which should be clearly understood and 
viewed as legitimate by all interested parties. 
These goals imply how program success is to be 
measured. Changes in the frequency of program 
clients' cocaine or heroin consumption and in their 
commission of (and subsequent apprehension for) 
violent crimes are typically the dominant themes of 
treatment outcome studies. With limited 

exceptions, changes in physical and psychological 
well-being, marijuana and alcohol consumption, 
general employment status, and the size of local 
drug markets are subsidiary issues. AIDS risk 
reduction as a measure of treatment outcome is 
only beginning to assume importance. 

This chapter first reviews the diverse interests that 
have shaped treatment, the interplay between these 
interests, and their implications for setting realistic 
treatment goals. The committee focuses especially 
on client motives for entering treatment. What 
finally spurs most clients into treatment is the 
desire to relieve some kind of immediate drug- 
related pressure or to avoid an unpleasant drug- 
related consequence. Concerns about legal 



jeopardy loom large among these motives and have 
been analyzed more extensively than all other 
factors combined. In this chapter, therefore, the 
committee carefully examines how the criminal 
justice system affects the drug treatment system 
and particularly considers the implications for 
treatment of the large and growing pool of drug- 
involved individuals over whom the justice system 
exerts (or tries to exert) various kinds of authority. 

Besides the criminal justice system, the workplace 
is the most significant formal institution potentially 
affecting referral to treatment, particularly through 
employee assistance and drug screening programs. 
Estimated productivity losses owing to drug 
problems add up to an impressive figure. There is 
limited evidence, however, about the connection 
between employee assistance or drug screening 
programs and drug treatment, and the data suggest 
that employer linkages are not a big part of the 
total treatment picture. 

The various and complex motives displayed by 
clients in treatment, the differing severities and 
depths of their problems, and the differential 
involvement of the criminal justice system or 
employers yield a spectrum of potential with 
respect to recovery from drug problems. 
Programs in turn have developed strategies for 
selecting or recruiting across that spectrum, within 
the limits of their clinical resources, organizational 
commitments, and institutional environments. 
Partial recovery, particularly in terms of reduced 
drug consumption and other criminal activity, is a 
realistic expectation for most clients in treatment at 
any one time. Full recovery is an achievable goal 
only for a fractional group, whereas no recovery 
can be expected for another fraction. 

In light of these observations, the most general 
conclusion of this chapter is that in setting and 
evaluating treatment goals, what comes out must 
be judged relative to what went in— and as a matter 
of more or less rather than all or none. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



81 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 4 



DIVERSE INTERESTS 

The notion of successful drug treatment has many 
possible shadings. A number of drug treatment 
goals have been overtly or implicitly advanced in 
authoritative statements over the years (American 
Bar Association/American Medical Association, 
1961; Office of Drug Abuse Policy, 1978; Office 
of National Drug Control Policy, 1989; Besteman, 
1992; Courtwright, 1992). These goals are 
diverse enough that success in reaching one of 
them (although it may be related to other goals) is 
not necessarily a requirement for success in 
reaching the others. The following is a 
compendium of many of these treatment goals: 

■ substantially reduce the treated individual's use 
of illicit drugs—or, more stringently, end it 
altogether; 

■ substantially reduce— or end altogether— violent 
and acquisitive crimes by the treated individual 
against others; 

■ substantially reduce— or end altogether— the 
treated individual's consumption of legal 
psychoactive drugs, including alcohol and 
medical prescriptions such as methadone; 

■ reduce the treated individual's specific 
educational or vocational deficits; 

■ restore or initiate legitimate employment of the 
treated individual; 

■ change the treated individual's personal values 
to approximate more closely mainstream 
commitments regarding work, family, and the 
law; 

■ normalize or improve the treated individual's 
overall health, longevity, and psychological 
well-being; 

■ reduce specific drug injection practices and 
hazardous sexual behaviors, such as multiple 
unprotected sexual encounters, that readily 
transmit the AIDS virus between the treated 
individual and others; 



■ reduce the overall size, violence, 
seductiveness, and profitability of the market 
for illicit drugs; and 

■ reduce the number of infants born with drug 
dependence symptoms or other immediate or 
longer term impairments owing to intrauterine 
exposure to illicit drugs. 

The length of this list of goals and the specific 
variations within it (reducing versus ending a 
certain behavior, individual versus more broadly 
sociological effects) have two distinct although 
related origins. First, different governing ideas 
about drugs have instilled different aspirations, 
theories, and philosophies into the treatment 
system. Second, drug treatment episodes involve 
multiple parties, and the ultimate results of any 
treatment episode are shaped by the differing 
objectives and behavior of those parties. 

Analytically, the parties involved in drug treatment 
are individual clients entering treatment; clinical 
programs themselves, which offer different types 
of services; third-party reimbursers or payers of 
clinical expenses (e.g., insurers or public health 
bureaus); regulatory agencies or other monitors 
such as accreditors or utilization managers, who 
enforce or evaluate program compliance with 
specific legal or clinical standards ; family members 
or others who are personally involved with 
individuals entering treatment; agencies that have 
legal or client relationships with these individuals, 
such as criminal justice agencies or employers; and 
the public through its appointed and elected 
representatives. 1 

' These categories of Interest in treatment are not necessarily 
separate In practice. Family members may have legal relations 
with the individuals in treatment in the form of marital and 
parental responsibilities; the family or the individual may take 
full or partial financial responsibility for treatment charges; 
employers and criminal justice agencies are not only bound to 
some individuals in treatment by formal contracts or writs but 
may also be paying for the treatment; payers such as state 
agencies often double as program regulators; employers, agents 
of justice, and, of course, clinicians often develop strong 
personal concern for their clients within the professional 
framework of service or supervision. Furthermore, although 
some parties to treatment deal with each other only in a single 
episode, others do so across many episodes. 



82 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



DEFINING THE GOALS OF TREATMENT 



The goals of clients, clinicians, program managers, 
payers, regulators, politicians, and other interested 
parties are often imperfectly matched. Conflicts 
and competition for control of clinical decision 
making are common. This pattern is visible not 
only in particular cases but also more broadly, as 
drug treatment policies, practices, and capabilities 
evolve with accumulating experience and vary with 
the changing balances between governing ideas. 

For example, the moral censure of drugs and the 
desire to reduce the prevalence of drug-related 
crime were early and clear influences on the 
development of publicly supported treatment 
programs. It is impossible to understand the 
growth of the national treatment system apart from 
the national policy focus on cutting down street 
crime. But compassion for the suffering of the 
addict has also been a factor, together with a 
strong current of concern, especially in the 1960s, 
about improving economic opportunities in urban 
neighborhoods badly troubled by poverty, drugs, 
racial discrimination, and other problems. 
Concern has centered as well on protecting the 
civil rights and restoring the human dignity of 
drug-dependent individuals. In this context, 
community programs were viewed as a source not 
only of therapy for the treated individual and 
crime control for all of his or her neighbors but 
also of jobs, identity, community empowerment, 
and political achievements (Vocational 
Rehabilitation Administration, 1966; Brotman and 
Freedman, 1968; Martin and Isbell, 1978; Attewell 
and Gerstein, 1979; Besteman, 1992; Courtwright, 
1992). 

In contrast, most privately reimbursed drug 
treatment programs began with a much firmer 
adherence to the medical perspective associated 
with treating dependence on alcohol as a disease, 
a perspective with very different legal 
ramifications and in particular an orientation 
toward restoring employees to satisfactory job 
performance. Private treatment programs have 
also placed great emphasis on the dignity—or 
destigmatization— of the afflicted individual 
(Wiener, 1981; Institute of Medicine, 1990; 
Roman and Blum, 1992). More recently, the fear 
of harmful or criminal behavior—including drug 



transactions at the work site and negligence in job 
performance that might lead to injury or loss of 
life—has become a significant factor as well (Gust 
and Walsh, 1989). Most recently, high levels of 
concern about increasing expenditures on private 
treatment for drugs, alcohol, and mental illness 
(and every other health cost) are affecting the 
private treatment sector. 

Plurality of interests is not a phenomenon unique 
to drug treatment, and it is not an insuperable 
obstacle to setting achievable goals. Even with 
clearly divergent intentions, different parties may 
be able to strike a bargain— that is, agree on a 
"social contract" for treatment— that everyone 
involved considers favorable, even though each 
party may get something less— or more— than it 
originally bargained for. The major result of 
complexity for present purposes is that it makes 
treatment processes highly contingent. If 
participants have differing goals, treatment 
processes are more susceptible to breakdown 
through client attrition or discharge, staff 
demoralization or mismanagement, program 
closing, or withdrawal of participation by a payer 
or other external agent. 

In light of the diversity of treatment goals and the 
differing motives that underlie them, it is 
important to develop realistic expectations about 
what treatment can usefully accomplish. The 
principal issues reduce to a few central and 
relatively enduring questions: Why do individuals 
enter drug treatment? What are the implications of 
entry motivations for setting clinical goals? What 
are the actual and the optimal goals of drug 
treatment and the criminal justice system? What 
are the supporting relationships between them? 
Between drug treatment and employers? What 
should be the minimum acceptable results of 
treatment— partial or only full recovery? 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



83 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 4 



REASONS FOR SEEKING TREATMENT 

Individuals who seek admission to drug treatment 
offer a variety of reasons for doing so (Anglin et 
al. 1989b; Hubbard et al., 1989). The reasons 
they give are illuminating, although their logic 
proves to be unintelligible in some cases, and they 
may be evasive or deceptive in others. Three 
fundamentals are present in virtually every such 
instance. First, the applicant for admission to drug 
treatment has one or more uncomfortable and 
fairly urgent problems to resolve. Typically, the 
problems entail noxious physical or psychological 
stimuli (a serious infection, chronic depression), 
sharp social pressure (a felony case, an angry 
spouse), or the imminent threat of something quite 
unwelcome (e.g., imprisonment or assault). 
Second, the problems are related to drug use, 
although the client may or may not view them as 
issues separate from drug consumption. In fact, 
the relative severity of drug abuse or dependence 
may be only loosely coupled with the severity of 
the presenting problem. Third, the individual is 
ambivalent about seeking treatment. 

Motives do not necessarily translate directly into 
outcomes. Reconfiguring client motivation is a 
fundamental clinical objective of many if not all 
good treatment programs. Moreover, there is 
reason to think that treatment processes affect 
individuals to some degree regardless of their 
initial motives. Nevertheless, the cardinal 
importance of the initial motivation to seek 
treatment is that these motives are likely to 
influence the probability that the client will stay in 
treatment long enough for the therapeutic process 
to take effect. For this reason, it is worthwhile to 
delineate treatment motivations in some detail. 

The kinds of problems that lead applicants to seek 
treatment are well summarized in the scales of the 
Addiction Severity Index, a diagnostic screening 
interview and rating method designed to yield "a 
subjective estimate of the client's level of 
discomfort in seven problem areas commonly 
found in alcohol and drug dependent individuals" 
(McLellan et al., 1985:iii). The following 
categories are rated for severity: 



■ medical status (lifetime hospitalizations 
[excluding drug detoxification or treatment], 
chronic medical conditions, disabilities, severe 
symptoms in past 30 days [excluding drug 
withdrawal, intoxication, or overdose effects]); 

■ employment/support (level of formal education 
and training, occupational type, usual 
employment pattern, past 30 days' 
employment, income level and sources, 
dependents, recent job-finding efforts [if 
applicable]); 

■ drug use (use during past 30 days, recent 
dependence/abuse symptoms, lifetime use, 
length and date of last abstinence, lifetime 
overdoses and detoxifications, previous 
treatment episodes, recent daily cost of drugs); 

■ alcohol use (use during past 30 days, recent 
dependence/abuse symptoms, lifetime use, 
length and date of last abstinence, lifetime 
overdoses and detoxifications, previous 
treatment episodes, recent daily cost of 
alcohol); 

■ legal status (whether legal jeopardy prompted 
application, whether client has an active case 
pending or is on probation or parole, lifetime 
arrests by type, number of convictions and 
incarcerations, recent crimes committed); 

■ family/social relationships (marital status and 
satisfaction, living arrangements and 
satisfaction, relations with friends, recent and 
past conflicts with family or friends); and 

■ psychiatric status (treatment episodes, 
symptoms of depression, anxiety, confusion, or 
aggression during lifetime and in past 30 days, 
suicide attempts). 

The literature on admission to treatment, much of 
which reports on the use of the Addiction Severity 
Index or similar instruments and reflects an 
abundance of clinical experience, indicates that 
treatment is sought primarily when there is a 
negative or threatening situation to be alleviated in 



84 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



DEFINING THE GOALS OF TREATMENT 



any one— or more— of these areas (Brown et al., 
1971; Ball et al., 1974; Gerstein et al., 1979; 
Hubbard et al., 1989). 2 Moreover, studies show 
that applicants often report either an unsuccessful 
attempt to deal with the admitting complaint 
without seeking treatment or an earlier successful 
resolution of this or a similar problem (at least 
temporarily) with the aid of treatment. Because 
some problems can be intermittent, yielding to 
quick solutions but returning again and again to 
trouble and frustrate the individual, initial brief 
flirtations with treatment are often followed by 
later, more extended episodes. In fact, half or 
more of a mature program's admissions can be 
expected to be repeat admissions to that program- 
without counting time spent in other programs. 
The prevalence of repeat admissions is generally 
highest in methadone programs, which require 
documentation of previous relapses and have the 
oldest clientele. In a typical long-standing 
methadone program, two-thirds of the clients are 
second or later admissions (Allison et al., 1985; 
Hubbard et al., 1989). 



2 Because a large proportion of the available research literature 
on patterns of drug treatment motivation is drawn from studies 
of heroin addicts entering methadone and residential treatment 
in the 1970s, caution should be used in generalizing those 
findings to drug users of today. On the other hand, the street 
heroin addict of the 1970s was usually an experienced 
polydrug user, familiar with all manner of opiates (codeine, 
morphine, propoxyphene, dihydromorphinone), cocaine (always 
popular for intravenous or other use but not as widely 
accessible or as cheap as it is today), amphetamines, alcohol, 
marijuana, barbiturates, and other drugs. The heroin addict 
was distinguished largely by a strong preference for that drug, 
assuming its availability. Patients entering residential and 
methadone programs today are similar to those of earlier years 
but generally have higher levels of nonopiate use, especially 
cocaine. The durability over the years of drug experience 
patterns and other characteristics may also be true of 
outpatient counseling programs, whose clients have tended on 
the whole to be younger, less desperate economically, and 
more often oriented toward psychological interpretations of 
their problems (Sells et al., 1976; Hubbard et al., 1989). 
Seldom opiate users, these clients were and are heavy users of 
marijuana, alcohol, and now cocaine. 



Controlling drug use is virtually always a part of 
treatment motivation, but the extent or proportion 
of that part varies. It may be the sole objective of 
treatment entry, or it may be no more than a base 
from which superordinate objectives are to be 
achieved. These objectives can be very specific: 
for example, to withdraw completely from a local 
drug market to avoid violent recriminations for a 
dishonest transaction (stealing someone's drugs, 
acting as a police informant, etc.); to influence a 
prosecutor or judge to reduce a heavy criminal 
charge or sentence, thus yielding probation rather 
than jail or a shorter rather than longer term of 
incarceration; to complete probation or parole 
successfully; to save a job threatened by drug- 
related absenteeism, ill temper, or errors; or to 
stave off a family rupture, such as expulsion from 
a conjugal or parental home or the loss of custody 
of a child. 

The motives can also be quite general: to restore 
generally run-down physical health; to put one's 
life back together; or to find or regain a sense of 
self-respect. Perhaps the most general of reported 
motives is a pervasive sense of weariness or 
melancholy, a cumulative and demoralizing 
realization that the increasing trouble that comes 
with sustained abuse and dependence is leading to 
a dead end. Depending on the modality, one- 
quarter to one-half of a national sample of 
treatment admissions reported depressive and 
suicidal thinking (Hubbard et al., 1989). 

Recently (Kosten et al., 1988), as well as in 
previous years (Allison et al., 1985), health crises, 
problems involving serious jeopardy from the 
criminal justice system, and psychiatric/psych- 
ological problems are the most prominent 
motivations among those seeking relief from 
cocaine and opiate use in public programs. 3 In the 
case of women or married men, pressure 
precipitating admission to treatment often comes 
from family members; however, in general, these 
demographic types are a minority of those entering 
public programs. 



'Chapter 6 more thoroughly delineates how the public tier of 
programs differs from the private tier. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



85 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 4 



Pressure from the criminal justice system is the 
strongest motivation reported for seeking public 
treatment. Those who entered outpatient and 
residential programs in a 1979-1981 national 
sample of public program admissions were directly 
referred by the criminal justice system about 40 
percent of the time. Direct referral, however, is 
clearly a conservative measure of the broader 
influence of criminal justice pressure (Anglin et 
al., 1989b). Between one-half and two-thirds of 
admissions to these modalities had some form of 
legal supervision such as parole or probation. 
Very few methadone clients—less than 3 percent- 
were directly referred by justice agencies in the 
1979-1981 sample (Allison et al., 1985; Hubbard 
et al., 1989), but probation or parole status was 
quite common. In other studies, large proportions 
of methadone clients have indicated subjectively 
perceived pressure involving their legal status 
(Anglin et al., 1989b). 

Court orders or other criminal justice system 
referrals to treatment are not unknown in private 
programs, particularly in outpatient modalities 
(Harrison and Hoffmann, 1988; Hoffmann and 
Harrison, 1988). But it seems likely that these 
referrals are mostly drinking/driving rather than 
drug cases (the published statistics on private 
programs are dominated by alcohol admissions and 
do not differentiate motivations by primary 
substance problem). Threats from employers or 
family members as well as psychological anguish 
and personal health problems are prominent 
motivators in private-tier programs. 

The implications of criminal justice involvement in 
an admission to drug treatment are important. 
Clinicians recognize that an applicant who is on 
parole or probation or who has a case currently in 
court automatically brings a second (and perhaps 
a third or fourth) "client" along— that is, the parole 
officer, defense attorney, prosecutor, judge, and so 
forth. Sorting out the effects of program activities 
on the clinical client versus their effects on the 
criminal justice client is no easy matter. Is an 
individual to be counted a treatment success or a 
treatment failure if he or she complied perfectly 
with treatment rules but dropped out of treatment 
early when convicted and imprisoned on a 



preexisting felony charge and is still in prison at 
the 12-month follow-up? Is a client a treatment 
success or a treatment failure if he or she is on 
probation, refrains from drug-seeking behavior, 
but continues to live by larcenous activities- 
avoiding rearrest during the 12-month follow-up 
period? Should the client whose parole officer 
insists on almost daily contact be equated 
analytically with the client whose probation officer 
wants no more than a quarterly postcard? The 
client's progress during or after treatment may 
depend heavily on the detailed conditions of 
criminal justice supervision that applied when the 
client entered treatment. To understand this 
connection requires a closer look at the 
relationship between the criminal justice and 
treatment systems. 



CRIMINAL JUSTICE AGENCIES 
AND TREATMENT 



According to the estimates presented in Chapter 3, 
more than a million individuals now in custody or 
under criminal justice supervision in the 
community need drug treatment. Approximately 
1 in 10 of these individuals is estimated to be 
currently in treatment; probably a similar number 
have had previous exposure to treatment. These 
figures indicate the significance of the criminal 
justice system as an environment for drug 
treatment— an important environment now as it has 
been in the past (see Besteman, 1992; 
Courtwright, 1992; Phillips, 1992). In the eyes of 
the public, criminal offenders constitute the most 
worrisome component of the drug problem and 
bulk large in estimates of the costs to society of 
drug use. It is difficult to envision any expansion 
of drug treatment without an expansion in its 
overlap with the criminal justice system (sharing of 
clients/supervisees/inmates) . 

Linkages between the justice and treatment systems 
occur at numerous points. Drug-involved 
offenders are sometimes sent to treatment rather 
than adjudication, a process known as pretrial 
diversion. Many courts and correctional systems 
use commitment or referral to community-based 



86 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



DEFINING THE GOALS OF TREATMENT 



treatment programs as an adjunct to probation or 
conditional release (parole) from prison. There is 
also treatment within correctional facilities and 
correctionally operated or funded halfway houses. 

Although the number of individuals in the criminal 
justice system as a result of drug-induced offenses 
has always been appreciable, it is much greater 
now than in the past—even as recently as 5 years 
ago. This increase is due to the 15-year trend of 
massive growth in the criminal justice system itself 
and in particular to the growth in volume of its 
correctional services—that is, time behind bars. 
Between 1973 and 1988, the number of arrests 
made annually by police increased an estimated 50 
percent, from 8 million to nearly 13 million— much 
faster than the increase in the U.S. population. 
Overall, the police concentrated nearly all of this 
increased attention on adults: for example, from 
1978 to 1987, the number of juvenile arrests 
declined by 13 percent whereas the number of 
adult arrests increased by 37 percent. (These 
shifts greatly exceeded changes in the age 
distribution of the population.) Adult arrests for 
drug crimes have increased disproportionately: an 
estimated 848,000 out of 937,000 total drug arrests 
in 1987 were adult offenders (Jamieson and 
Flanagan, 1989). 

The consequences of arrest have also changed, and 
there is now a much greater likelihood than in the 
past that an individual convicted of a crime will 
spend time in custody and under subsequent 
community supervision. In 10 years, from 1978 to 
1987, the average daily jail census nearly doubled, 
from 156,000 to 290,000; in 15 years, the prison 
census more than tripled, from 204,000 in 1973 to 
625,000 in 1988 (Figures 4- la and 4- lb). Periods 
of imprisonment for felons sentenced to state 
prisons now average 2 to 3 years; the average 
imprisonment is somewhat less for drug offenses 
and somewhat more for violent offenses (e.g., 3 to 
5 years for robbery, 7 years for homicide). Total 
sentences extend much longer than the time served 
in prison. Under widespread mandatory release 
rules, about 45 percent of the sentence is usually 
spent in prison initially, with the remainder on 
parole, not counting reincarceration time as a 
result of parole violation. Altogether, about 3.3 



million individuals were under criminal justice 
supervision of one sort or another on the 
designated census days in 1987 compared with 1.3 
million in 1976. Three out of four of these 
individuals were in the community rather than 
behind bars. 

Court Referral to Treatment 

The largest effort to bring adjudicated populations 
into contact with treatment is court-ordered 
screening to assess suitability for placement in 
community-based treatment programs under 
pretrial or posttrial probation. A series of these 
types of court-related programs were organized 
beginning in 1972 under the Treatment 
Alternatives to Street Crime (TASC) program 
(Cook, et al., 1988). Originally created mainly to 
serve opiate addicts, the program soon became a 
common mechanism for diverting lesser drug 
cases, such as marijuana possession in small 
amounts, to avoid "clogging the justice system" 
with offenders who were nonviolent criminals. 

In a model program, TASC clinicians used pretrial 
screening to assess the treatment suitability and 
needs of drug-involved arrestees Identified either 
by urine tests, a previous record of drug-related 
arrests, or interviews. These assessments were 
then used to ensure that treatment would be 
offered to those who both needed it and met 
qualifying criteria (see Phillips, 1992). Under 
such a program, when an accused individual was 
deemed suitable for treatment and the prosecutor 
and court agreed, he or she could accept referral 
to a community-based treatment program and the 
pending case would be suspended or a summary 
probation issued. If the individual completed the 
program successfully, the pending charges were 
dismissed or the probation discharged. 

The federal "seed money" funding base for 130 
TASC programs in 39 states was withdrawn in 
1981, but 133 program sites in 25 states are now 
operating with support from state or local court 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



87 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 4 



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1970 1980 1988 



FIGURE 4-1 (a) Sentenced prisoners in state and federal institutions in the United States on December 

31 OT the years 1 925-1 986. Prison population data were compiled by a year-end census of prisoners held in custody in state 
and federal institutions. The 1988 figures are advance estimates subject to revision. Data for 1925 through 1939 include sentenced 
prisoners in state and federal prisons and reformatories, whether committed for felonies or misdemeanors. Data for 1940 through 1970 
include all adult felons serving sentences in state and federal institutions. Since 1971 , the census has included all adults or youthful 
offenders sentenced to a state or federal correctional institution with maximum sentences of more than one year. Sources: Flanagan 
and Jamieson (1988:484); Greenfeld (1989). 

(b) Rate (per 100,000 resident population) of sentenced prisoners in state and federal institutions in 

the United States On December 31 Of the years 1 940-1 988. The rates for the period before 1980 are based on the 
civilian population, which is the resident population less the armed forces stationed in the United States. Since 1980, the rates are based 
on the total resident population provided by the Bureau of the Census. Sources: Flanagan and Jamieson (1988:485); Greenfeld (1989). 



88 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



DEFINING THE GOALS OF TREATMENT 



systems or treatment agencies (Bureau of Justice 
Assistance, 1989). In addition, renewed federal 
support has recently become available as a result 
of the Justice Assistance Act of 1984 and the Anti- 
Drug Abuse Acts of 1986 and 1988. Some TASC 
programs have diversified, expanding from 
assessment and referral functions to counseling or 
testing; some currently contract with parole 
departments to assess and supervise prison 
releasees as well as probationers. 

Early formative evaluations indicated that some 
TASC programs were efficiently managed and 
successful in introducing many of their contacts to 
treatment for the first time. They also seemed to 
yield promising results in terms of lower 
recidivism. Nevertheless, it is impossible to draw 
conclusions about the effectiveness of the TASC 
diversion approach. As the coordinators of a 
national TASC network point out, "TASC had no 
solid data base or data collection mechanism in 
place that would allow for long-term evaluation 
and comparison of the program's impact on drug- 
related crime or on the processing burdens of the 
criminal justice system" (Cook et al., 1988:102). 

There are some data available, however, on the 
effects of TASC referral compared with other 
referral sources. Analysts of the national 1979- 
1981 Treatment Outcome Prospective Study 
(TOPS) developed a multivariate regression model 
of the effects of TASC referral compared with 
other client admission characteristics in residential 
and outpatient counseling programs (Collins and 
Allison, 1983; Hubbard et al., 1989). Criminal 
justice referrals to methadone programs in the 
sample were rare— too rare to permit reliable 
statistical results— but a substantial percentage (31 
percent) of those admitted to outpatient 
nonmethadone and residential therapeutic 
community programs in the TOPS project were 
referred by criminal justice agencies, largely 
TASC programs. 

After controlling for various preadmission 
characteristics (including criminal activity), TASC 
referral had a positive effect on the length of stay 
in treatment: retention increased for referred 
individuals by seven weeks on average in 



residential programs and six weeks for outpatient 
stays over the retention of nonreferred individuals. 
As Chapter 5 notes, longer retention is statistically 
associated with better response to treatment. 
These incremental differences, however, were not 
large enough to produce statistically significant 
differences in the outcome of treatment. At a 
minimum, this result showing increased retention 
means that legal pressure in the form of direct 
referral was clearly not detrimental to TOPS 
treatment outcomes, confirming the earlier results 
of 1969-1973 admissions to a national sample of 
programs (Simpson and Friend, 1988) and contrary 
to the reservations expressed by many clinicians 
before the implementation of TASC. 

There is growing interest in TASC-type programs 
and "coerced treatment" as a mode of relationship 
between the treatment and criminal justice systems. 
The experience with community-based treatment 
during the 1970s was certainly favorable. When 
neither the treatment programs nor the criminal 
justice system was overwhelmed by cases, the 
deals struck between defendants, the courts, and 
the programs appear to have had clinically benign 
or positive effects; clients so acquired did at least 
as well in treatment as clients entering as a result 
of other forms of pressure. Whether this finding 
will hold up under the current circumstances of 
vastly increased criminal justice case-processing 
burdens is not yet known. 



Prison and Parole Referral to Treatment 

The large numbers of drug-involved prison inmates 
(see Chapter 3) and their propensity over the 
course of many years to commit a high volume of 
violent crimes in the community (Nurco et al., 
1981a,b,c; Johnson et al., 1985) make the idea of 
treating the drug abusers and drug-dependent 
persons in this captive population an attractive one. 
Two objectives of prison— to isolate the criminal 
from doing harm in and to the community and to 
mete out punishment as promised by the law— do 
not require drug treatment. But a third purpose of 
prison, td deter the commission of future crimes 
by the convict after his or her release from 
confinement, could well be served by treating 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 4 



inmates— that is, if evidence supported the 
presumption that treatment would reduce drug use 
after prison and that this would in turn reduce 
recidivism. If one could efficiently and effectively 
deploy drug treatment in prisons, where so many 
drug-involved criminals are located, the potential 
reduction in community crime costs would be a 
large social benefit. A close look at the data on 
prisoners, drugs, and recidivism, however, leads 
to guarded expectations about whether and how 
much drug treatment might cut prison recidivism, 
notwithstanding its effectiveness in cutting drug 
use. 

The reason for caution is that prisons are currently 
functioning much like revolving doors for clients, 
whether or not they are heavily involved with 
drugs. Another way to express this notion is that 
individuals in prison are generally in the middle of 
an extended career in crime. Despite the massive 
expansion in numbers of prisoners, there is not 
much room in prisons for younger first offenders 
because of the large (and increasing) number of 
more senior, returning parole violators and 
multiple offenders. In 1978, a study of young 
adults on parole found that, within six years after 
release, 69 percent had been arrested and 49 
percent had been reincarcerated (Flanagan and 
Jamieson, 1988). Among a sample of 16,000 
prisoners released to parole in 1 1 states in 1983, 
the average parolee had 8.6 prior arrests on 12.5 
offenses, and 67 percent were on their second or 
later incarceration (Beck and Shipley, 1989). 
Sixty-two percent had been rearrested and 41 
percent reincarcerated by the end of the third year 
after release. In the 1986 survey, three-fourths 
(74 percent) of all state prison inmates had been 
incarcerated before, and half had been incarcerated 
at least twice before (Innes, 1988). 

Recidivism statistics also strongly suggest that 
longer (rather than shorter) incarceration— at least 
within the range generally incurred in today's 
prisons— does not necessarily reduce the probability 
of rearrest after release, although longer 
imprisonment by definition keeps criminals isolated 
from the community for longer periods. Beck and 
Shipley (1989) found that the rate of rearrest 
within three years of release was virtually the same 



for individuals serving as little as six months as it 
was for those serving as much as five years. Only 
the 4 percent of prison releasees who had served 
terms longer than five years— almost all of whom 
were convicted murderers, rapists, and armed 
robbers with multiple convictions— had a lower rate 
of rearrest (by about 14 percentage points) than the 
others. The lack of correlation of length of 
imprisonment (up to five years) with the 
probability of rearrest held steady after controlling 
for a variety of separate factors that predicted 
rearrest. 

Drug involvement as such was not a principal 
feature differentiating recidivists from 
nonrecidivists in this population. In a multivariate 
logit analysis, five categorical attributes were 
found to increase the probability of recidivism: age 
when released (<25, 25-34, 35+), number of 
prior convictions (7+, 4-6, 1-3), prior probation 
or parole revocations (yes /no), prior incarceration 
(yes I no), and whether the current offense was for 
an acquisitive crime, namely, robbery, burglary, 
or theft (yes/no). More than 90 percent of 
prisoners with positive criteria on all five of these 
risk factors were recidivists (rearrested), as 
opposed to only 17 percent of prisoners with five 
negative criteria. With these five major factors 
(which are dominated quantitatively by age and 
number of convictions) taken into account, 
considering whether the individual had ever had a 
drug arrest (and 38 percent of the sample had) 
spreads these probabilities out by only about two 
more percentage points. 

Although the prison-based studies show rather 
limited differences in recidivism between heavily 
drug-involved prisoners and other prisoners, there 
is ample evidence that, for those who use opiates 
and cocaine heavily, the relation of illicit drug 
consumption to current other criminality when in 
the community is a close one. When heavy drug 
consumers cut out or cut back on their drug use, 
their criminality of other kinds is also dramatically 
lower (Ball et al., 1981; Johnson et al., 1985; 
Speckart and Anglin, 1986); however, the causal 
direction here is not clear. The relationship 
between illicit drug use and other criminality tends 
to be reciprocal and "synergistic," each 



90 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



DEFINING THE GOALS OF TREATMENT 



independently increasing the likelihood of the 
other. If drug treatment involves close 

surveillance in the community and a therapeutic 
focus on factors related directly to criminal 
occupation as well as to recovery from drug 
seeking, treatment may be able to affect the 
recidivist tendencies of prisoners and parolees to a 
greater degree than the modest leverage indicated 
by today's discouraging statistics on recidivism 
generally. 

Preliminary Conclusions 
About "Mandatory Treatment" 



to vitiate treatment effectiveness, and it probably 
improves retention to some extent. 

The relevant evidence on criminal recidivism 
during and after "mandatory" treatment is 
reviewed in Chapter 5. It concerns mainly the 
effects of therapeutic prison programs paired with 
intensive parole supervision and postrelease 
continuity in community treatment. Some of these 
programs are at the discretion of the sentencing 
authority only, but more of those on which 
evidence is available involve initiative on the part 
of the inmate. 



The drug treatment and crime control systems 
share important goals— in particular, their clients' 
pursuit of less criminal and drug-involved lives. 
There are probably 40,000 individuals in drug 
treatment programs in jail or prison, out of nearly 
1 million persons in custody on any given day. 
More broadly, many courts and correctional 
systems use commitment or referral to 
community-based treatment programs— usually 
programs involving close supervision, such as 
residential facilities— as alternatives or adjuncts to 
probation or parole. Half or more of the several 
hundred thousand admissions to community-based 
residential and outpatient drug treatment programs 
are on probation or parole at admission. These 
statistics are a direct manifestation of the criminal- 
medical policy idea (see Chapter 2). 

There is frequent favorable reference today to 
"mandatory," "compulsory," or "required" 
treatment. The most important reason to consider 
these or related schemes to force more criminal 
justice clients into drug treatment is not that 
coercion may improve the results of treatment but 
that treatment may improve the rather dismal 
record of plain coercion—particularly 
imprisonment— in reducing the level of intensively 
criminal, antisocial, and drug-dependent behavior 
that ensues when the coercive grip is relaxed. In 
fact, getting more criminal justice clients into 
treatment could improve the results of criminal 
justice sanctions even if it actually diminished the 
average effectiveness of treatment. As it turns out, 
however, contrary to earlier fears among 
clinicians, criminal justice pressure does not seem 



Most criminal justice pressure on community 
program clients does not involve forcing them into 
treatment. The pressure is more often indirect or 
involves some voluntary interest by the client. In 
the indirect case, the court (or other justice 
agency) simply insists that the client stay free of 
drugs or else be remanded into custody. The 
individual may then choose to seek treatment under 
the assumption that avoiding drug use (or at least 
avoiding abuse or dependence, which are far more 
troublesome and difficult to conceal) will be 
facilitated. In other cases, the court or other 
agency may offer the client a choice (through plea 
bargaining or negotiation): generally, a term in 
prison versus a period of probation or parole with 
treatment. 

Criminal justice referral to treatment occurs for 
several reasons, including the belief that treatment 
may help reduce drug use and other criminal 
behavior. Increasingly, there is strong motivation 
to relieve court and prison overcrowding. 
Utilizing the treatment option takes responsibility 
for the case somewhat out of the criminal justice 
system, reduces the high cost of continuing 
incarceration, fends off the hanging sword of 
court-ordered population ceilings, and promises to 
deliver a degree of supervision beyond what 
probation or parole offices may typically be able to 
provide. 

When referral occurs to relieve overcrowding, 
however, the stipulation "go to treatment and 
comply with the program, or risk being returned to 
custody" loses its credibility. The more 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 4 



overcrowded and strained the criminal justice 
system, the less pressure it can muster to help 
push people into seeking and complying with 
treatment. In view of the unrelenting growth of 
criminal justice populations, which threatens to 
swamp prison capacity and adjudication processes 
alike, any increase in these systems' ability to 
pressure people to enter or comply with treatment 
seems unlikely. Rather, increasing treatment 
capacity and improving the quality of treatment 
programs may be a way to keep the justice system 
situation from becoming even worse. 



EMPLOYERS AND TREATMENT 



Two-thirds to three-quarters of clients in the 
private drug treatment sector are drawn from the 
employed population (Comprehensive Care 
Corporation, 1988; Harrison and Hoffmann, 1988; 
Hoffmann and Harrison, 1988; Smith and 
Frawley, 1988). Just as the criminal justice 
system has been a locus of pressure toward 
treatment admission, employers have been seen as 
a similar lever for drug-abusing and drug- 
dependent employees. As a result of management 
concerns, union interest, and governmental 
actions, the role of employers in relation to drug 
treatment has become more extensive in the 1970s 
and 1980s than in previous years. Developments 
in the past two decades have been institutionalized 
in two kinds of drug-related workplace activities: 
employee assistance programs (EAPs) and drug 
screening programs (DSPs). Although they have 
some common qualities, there is a clear disjunction 
in the purpose and operation of these two kinds of 
programs. 



that the great majority of alcohol-dependent and 
alcohol-abusing individuals are not impoverished 
skid row inebriates but are spread throughout the 
working, middle, and upper classes, including the 
ranks of corporate executives (Beauchamp, 1980; 
Moore and Gerstein, 1981; Roman and Blum, 
1987, 1992; Institute of Medicine, 1990). Today, 
EAPs serve a variety of management and employee 
benefit purposes, including the therapeutic 
management of drug problems. 

The original role of the EAP was to enable 
supervisors (through an aggressive policy of 
supervisory training) to identify suspicious job 
deterioration before the situation was hopeless and 
to engage in "constructive confrontation "-- 
originally called "constructive coercion" (Trice, 
1966)~of the employee regarding his or her 
alcohol problem. This confrontation would then 
be followed by referral to treatment and follow-up 
as appropriate. Clearly, the goal of the EAP in 
this process was to return the deteriorating 
employee to satisfactory job performance; in 
pursuit of that goal, it provided training, assisted 
in confrontations, and made referrals. It was 
generally based in a central office and had its own 
credentialed specialists affiliated with the personnel 
or health department of a firm or union. 

EAPs are common in larger, unionized firms and 
agencies. 4 About 26 million workers in private 
industry (31 percent of such workers; Bureau of 

4 A Bureau of Labor Statistics 11989b) survey indicated that 
EAPs are available to 4 percent of workers in establishments 
with less than 10 employees and 87 percent of workers in 
establishments with more than 5,000 employees. The same 
variation applies to drug screening programs, which are 
available to 1 percent of workers in sites with less than 10 
employees and 68 percent of workers in establishments with 
more than 5,000 employees. 



Employee Assistance Programs 

Employee assistance programs, or EAPs, began in 
the 1960s and were originally associated with the 
alcohol treatment field, resulting from the growth 
of concern about "hidden" alcoholics in all social 
classes. Indeed, it is only in the past 20 years that 
experts and activists have driven home the idea 



92 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



DEFINING THE GOALS OF TREA TMENT 



Labor Statistics, 1989b) and 10 million public 
employees now have access to an EAP. There has 
been steady growth: about 25 percent of Fortune 
500 firms had EAPs in 1972, 57 percent had them 
in 1979, and virtually all such firms operate 
programs today. But EAPs have changed over 
time. Functions have been added (e.g., benefit 
management, brief counseling), and an industry of 
external EAP contractors has arisen. More 
significantly, the programs' original focus on 
alcoholism has broadened and now constitutes a 
larger social problem or "industrial social work" 
orientation: only one- third of a typical EAP's 
cases now involve alcohol or drug abuse, and the 
majority of cases are informal (and therefore 
confidential) "self-referrals" rather than formal 
supervisory referrals (Backer and O'Hara, 1988; 
Roman and Blum, 1992). All of these trends have 
made EAPs more and more like an employee 
benefit— one component of a total compensation 
package— and less and less like a management tool 
for maintaining desired levels of employee 
productivity on a day-to-day basis. 

Along with the reduced role of alcohol in EAP 
goals and activities, there has been increasing 
attention to drugs; this trend is in part the result of 
a generational change, as those entering the work 
force after 1970 increasingly were found to be 
consuming illicit drugs as well as alcohol. The 
rapid emergence of marijuana and cocaine use in 
the work force of the 1980s met the expansionary 
crest of spreading EAP services and explicit 
substance abuse insurance coverage for employees 
and their families, generating a rapid increase (but 
from a very low base) in drug treatment referrals. 
In particular, the attention of EAPs to mixed 
alcohol and cocaine problems coincided with the 
addition of drugs to the scope of the private tier of 
alcohol treatment providers, with widespread and 
often highly publicized offerings of combined 
treatment (chemical dependency) protocols. 

Typically, according to the corporate respondents 
surveyed by Roman and Blum (1991), about 4 
percent of the employees in a firm providing an 
EAP consult the EAP in a given year. About 1.5 
percent of employees specifically present a 
substance abuse problem, and in two-thirds of 



these cases, only alcohol, and not drugs, is 
clinically significant. These results correspond 
with a variety of data from individual firms 
reviewed by this committee during site visits. The 
bottom line is that about 0.5 percent of employees 
in an average EAP firm can be expected to consult 
the EAP (usually on a self-referred basis) for 
serious drug problems in a 12-month period. 
Applied to a work force of about 36 million 
individuals with access to an EAP, this suggests 
that about 180,000 candidates for referral to drug 
treatment may currently be seen by EAP 
counselors. 

Yet, as the changing role of EAPs suggests, the 
actual linkage of employers to treatment has been 
much less substantial than the above figure 
suggests. Employer referrals or pressures play 
only a small role, based on the few data sets 
available on referral to private programs. 
According to counselor discharge evaluations 
supplied by programs subscribing to the Chemical 
Abuse/Addiction Treatment Outcome Registry 
(CATOR) follow-up system (Harrison and 
Hoffmann, 1988; Hoffmann and Harrison, 1988; 
these data mainly pertain to alcohol clients), the 
employer is mentioned as a primary .motivator for 
treatment admission by only one-sixteenth of 
inpatients and one-tenth of outpatients. In these 
private-tier, midwestern, largely insurance-paid 
chemical dependency programs, greater numbers 
of both inpatients (one in seven) and outpatients 
(one in three) were reportedly motivated to seek 
treatment primarily by the courts— most presumably 
as drinking/driving cases— rather than by their 
employers. 



Drug Screening Programs 

The growth of drug screening programs (DSPs) 
has been a significant development of the 1980s, 
encouraged strongly by the federal government and 
most recently required of federal contractors by 
the Drug-Free Workplace Act of 1988 (P.L. 100- 
090, Title V, implemented by Executive Order 
12564, 1989). The growth of DSPs has been led 
by large companies, and there is increasing 
regulation by the states (Intergovernmental Health 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



93 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 4 



Policy Project, 1989). These programs are drug 
specific and rarely, if ever, test for alcohol. 

There are two fundamental kinds of DSPs: for 
employees and for job applicants. Most of the 
employee testing takes place at scheduled intervals 
(e.g., annual physical exams, prospective 
promotions to sensitive positions) or for probable 
cause rather than on a random basis, although 
random testing has attracted the most attention and 
controversy. In 1988, about 16.6 million or one- 
fifth of private-industry employees worked in 
organizations with some kind of DSP. Two-thirds 
or 11 million of these employees were in 
establishments that have programs to test current 
employees, and 14.7 million were in workplaces 
that test applicants (Bureau of Labor Statistics, 
1989b). Applicant testing is the lion's share of 
DSP activity: about 953,000 employees and 3.9 
million job applicants were tested in the 12 months 
prior to the mid- 1988 Bureau of Labor Statistics 
survey. About 84,000 employees (8.8 percent of 
those screened) and 466,000 applicants (11.9 
percent of those screened) tested positive. Most of 
the positive tests yielded evidence of cocaine or 
marijuana use. 5 



How Employers View Drug Treatment 



Of the half-million positive DSP tests of job 
applicants, it is unknown how many— if any—lead 

6 These DSP results are not necessarily representative of o verall 
employee or applicant drug consumption patterns. Most 
employee testing is based either on a strong suspicion of drug 
use (which greatly raises the likelihood of positive results) or 
the necessity to maintain a drug-free status in positions with 
particular safety hazards (which probably lowers that 
likelihood). In addition, these results most likely underreport 
casual use (false negatives) because of conservative cut-off 
levels, limited test sensitivity, and intervals between periods of 
use; however, they may also include a number of false 
positives (American Medical Association Council of Scientific 
Affairs, 1987). The errors are thus in different directions and 
of different magnitudes, and it is impossible to estimate thenet 
resulting bias. 



to treatment. The overwhelming rule, however, is 
that employers simply deny the job application 
when the test is positive. Drug screening 
programs thus are used far more frequently to 
keep people from working than to make them fit 
for it. As for employee testing, about 60,000 of 
the estimated 84,000 positive results occurred in 
firms with EAPs, which are more likely than 
employers without EAPs to consider treatment an 
appropriate response. Nevertheless, in one survey 
of 1,238 EAPs (Backer and O'Hara, 1988), 
virtually none reported that more than "0-5 
percent" of their clients entered treatment as a 
result of DSP activities, even though more than a 
third (35 percent) of the reporting EAPs were in 
firms or agencies with drug testing. 6 

The evidence, although thin, thus suggests that 
there are sharply fewer annual employer-related 
referrals to treatment than the combined figure 
from EAPs and DSPs of up to 264,000 potential 
cases. In the committee's judgment, a figure of 
around 50,000 annual employer referrals to 
treatment, which is to say, direct employer 
pressure to seek treatment, seems plausible. This 
number is roughly equal to the daily census of 
drug treatment clients inside jails and prisons; it is 
a fraction of the annual criminal justice referrals to 
treatment through TASC and related programs. 
Most of the employer referrals are to private-tier 
programs, about which research knowledge is 
especially sparse (see Chapter 5). Until that base 
of knowledge is improved, no better estimate is 
possible. 

6 The comparable figure in the Bureau of Labor Statistics sample 
was that 45 percent of EAPs were in DSP firms. This 
comparison is noted because the Backer and O 'Hara survey 
needs to be viewed cautiously; the survey response rate was 
16.2 percent, and the sample of EAPs was not selected from 
an enumerated list or sampling framework. The U. S. General 
Accounting Office (1988) reviewed 10 other surveys of 
employers from 1985 to 1989. None of them were 
representative samples, and most had low return rates similar 
to the Backer and O 'Hara survey. Most companies indicated a 
willingness to refer current employees with positive drug 
screening results to a rehabilitation program on a case-by-case 
basis, but there was no indication how often referral took place 
in practice. In 439 EAPs surveyed by Blum and Roman in 
1984-1985, those with DSPs reported the same rate of drug- 
related referrals as those without screening programs. 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES No. 2 



DEFINING THE GOALS OF TREATMENT 



Despite the large productivity implications of drug 
abuse and dependency, employers appear to use 
their potential leverage very gingerly with regard 
to treatment. They do voice great concern about 
the cost implications of covering drug treatment 
under employer-sponsored health plans. This 
seeming disparity derives from two factors. One 
is the tendency to lose sight of drug treatment as 
such within the much larger pool of alcohol and 
psychiatric ("nervous and mental") benefit claims. 
The second factor is the high growth rate in 
payouts for inpatient care for drug abuse diagnoses 
that are attributable not to employees but to their 
covered dependents, particularly adolescent girls. 
These issues are assessed further in Chapter 8, but 
their prominence strongly reinforces the 
impression that employers view drug treatment 
more as part of the problem of high employee 
benefit costs than as part of the solution to a 
pervasive productivity problem. 



AMBIVALENCE AND THE SPECTRUM OF 
RECOVERY 



Even drug consumers who are badly impaired or 
severely pressed by legal or other problems are 
often ambivalent about seeking treatment. They 
may yield in the end only because pressure from 
family members, the law, deteriorated health, 
psychological stress, or a combination of such 
factors becomes too intense to deny. They may 
also find themselves impelled to seek treatment 
finally because attempts to relieve the pressure 
through other means, such as unassisted self- 
control, have proven futile. 



mistake the satisfaction of drug wants and needs 
for the satisfaction of most (if not all) other wants 
and needs. This mistake is readily compounded 
because sustained drug experience may make an 
individual quite adept at meeting drug-specific 
requirements (e.g., knowing which drugs to buy 
and from whom, how to get the most effect from 
a drug) and less capable of satisfying other 
requirements, such as holding down a job. In 
addition, there is moral and logistical support for 
drug behavior to be found among other drug 
consumers, who may be close friends and family 
members. Their moral support for drugs may well 
extend to active disapproval of treatment (Eldred 
and Washington, 1976). 

Finally, most forms of drug treatment, if 
implemented according to best clinical practice, 
are rigorous. These programs impose 

environmental schedules and controls and require 
a substantial amount of emotional work and 
behavioral change on the part of the client. Their 
requirements range from such logistical conditions 
as restrictions on mobility, keeping appointments 
for psychotherapy, and urine testing to more deep- 
seated issues such as clinical frankness and 
movement toward behavioral and emotional 
maturity. Unfortunately, clinical rigor has 
probably diminished in recent years as declining 
resources cut deeply into program operating 
capabilities. For example, programs that formerly 
used once-a-week urine testing have cut back in 
many cases to monthly tests, in compliance with 
minimum federal regulations. Psychotherapy and 
other service hours have typically been reduced by 
half or more from earlier levels (Hubbard et ah, 
1989). 



Ambivalence toward treatment has several sources. 
First, it is always necessary to remember that the 
population involved like the drugs they consume. 
Drugs "work" for them, providing psychological 
and physical effects they have learned to value. 
Beyond the drug effects as such lie personal 
satisfactions for drug consumers in their ability to 
acquire and use drugs, both of which require a 
certain amount of practical and ritual competence 
(Preble and Casey, 1972; Johnson et ah, 1985). 
It is easy, moreover, for the heavy consumer to 



Nevertheless, even at reduced levels of program 
rigor, drug consumers' ambivalence about 
participating in clinical procedures or program 
activities may lead to their breaking off the 
admission process before it is completed. 
Ambivalence generally continues during the first 
days and weeks of treatment exposure, presenting 
a stubborn challenge to clinicians. Where 
admission pressures such as threats to personal 
safety, legal jeopardy, health problems, or other 
motivational sources are not especially durable and 



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the individual's goal of immediate relief is not 
accompanied by the need to protect positive assets 
or by a strong desire for longer term relief from 
drug seeking and its associated life circumstances, 
it is often difficult to overcome a person's 
reluctance to comply with demanding clinical 
requirements. Remitting pressures and continuing 
ambivalence undoubtedly contribute appreciably to 
the rapid early attrition curves seen in many drug 
treatment programs. 

These judgments about the relation of motivation 
and attrition are difficult to prove or quantify with 
available research evidence. All measurements 
that correlate with early treatment dropout do so 
rather weakly (Hubbard et al., 1989). This 
weakness may be the result of imprecision in 
measuring the motives for seeking treatment and 
imprecision inherent in the dichotomies typically 
employed in client surveys, such as self- referral 
versus other- referral, on probation or parole versus 
not on probation or parole, and no versus any 
"perceived legal pressure." It may also be the 
case that a more general quotient or index of 
treatment motivation needs to be developed, taking 
into account the balance between severity of 
problems, attractiveness of assets in jeopardy, and 
features of the client's extended individual history 
of drug experience. Measurement problems aside, 
it is clear that initial motivation is but one element 
in a constellation of factors affecting the duration 
of treatment. Some of the other elements that 
have been studied, including qualities of program 
staff and specific treatment procedures, are 
reviewed in Chapter 5. 



Full, Partial, and Nonrecovery 
from Drug Problems 

An individual's initial motivation with respect to 
changes in his or her drug consumption varies 
from a desire for full recovery— aiming to achieve 
a lifetime of continuous abstinence— through more 
modest intentions, which can be called partial 
recovery, to not seeking recovery at all. The 
desire for lifelong abstinence is straightforward 
and easy to understand, but it is far from universal 
among clients in treatment. It is most likely to be 



found among those for whom the retention of 
valuable personal assets hinges on abstinence, 
forming a powerful counterweight to the 
attractions of drugs. More affluent and socially 
conventional clients often have a comfortable 
home, a good job, respectability, and an intact 
non-drug-using family at the time of admission, 
and these assets serve as incentives that support 
abstinent motivation. Less advantaged clients, 
those who are without most or all of these 
attributes or without evident prospects for securing 
them (even though they may greatly desire such 
things), have few preadmission assets. Indeed, it 
may be that the only resources these individuals 
possess, the threat of whose loss acts as an 
incentive, are their lives and their rights as 
citizens— even as second-class citizens from whom 
certain fundamental rights have already been 
withheld, as in the case of parolees. In other 
words, for socially disadvantaged individuals who 
are heavily involved in drug use and whose 
positive personal assets are limited, avoiding a 
long stretch in prison may be the only motivational 
counterweight strong enough, at the outset, to 
balance the lure of easily available drugs. The 
ethical and civil rights implications of this 
inequality between the well-off and the 
disadvantaged are troubling; nevertheless, this 
description accurately depicts the current state of 
affairs. 

Clients may formulate exterior motives for 
entering treatment as "to get [someone] off my 
case. " External pushes are usually allied to some 
degree with positive pulls or motivations to 
change. The positive motives are often not strong 
enough in themselves to initiate or sustain 
compliance with treatment, but reinforcement 
through external pushes into treatment and 
therapeutic pressure within treatment may be 
effective in doing so. 

Clients often enter treatment as a self-conscious 
strategy to achieve partial recovery. That is, their 
purpose is to use treatment to help them gain 
control over their drug behavior— not to extinguish 
it entirely but to enable them subsequently to 
moderate it, perhaps for the first time in many 
years (e.g., to reduce their use to the manageable 



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DEFINING THE GOALS OF TREATMENT 



level they may have attained during an earlier, 
happier period of their drug-using careers). The 
purpose of these clients may be, for example, to 
keep daily drug use down to a clinical prescription 
(perhaps methadone, a tranquilizer, or a mood 
elevator) plus some drinks and an occasional "hit" 
of marijuana, methamphetamine, or some other 
"treat. " Most important to this kind of applicant 
or client is to avoid taking the major drug of 
dependence (usually cocaine or heroin) or, if a 
"slip" happens in a moment of weakness, to have 
some protection and instantly available help against 
falling back into a full-blown, full-time habit 
(Wesson and Smith, 1985). These are users for 
whom treatment is a crutch, but one that produces 
both individual and social benefits. The challenge 
they offer to the quality of counseling and clinical 
acumen in a program is to make the crutch 
perform well, to satisfy and at the same time try to 
upgrade their recovery aims. 

In contrast to the motive toward partial recovery, 
some clients have no wish at all to modify their 
drug consumption but seek program admission 
only to falsely certify such intentions in the eyes of 
family members or criminal justice agents (or 
both). How programs respond to these "bad 
attitudes" varies. Some programs work hard to 
discover and stop any deception on the part of 
clients and to confront them early on with the 
choice either of working to reform these attitudes 
and their accompanying behavior or of leaving 
treatment. Other programs subscribe to the 
philosophy that drug use and related attitudes such 
as deception (including self-deception or denial) 
are the fundamental clinical problems for which 
the person was admitted and that, for such cases, 
staying in treatment represents an improvement in 
health status, even if the improvement is small. 
Therefore, it would be impermissible to deny these 
individuals further treatment. It is a truism among 
clinicians, however, that such persons are probably 
heading for even deeper trouble, and later many of 
them seek treatment again with a different attitude. 



Setting Realistic Goals 

Drug problems that are serious enough to need 
treatment are usually chronic and relapsing in 
nature—generally, they are embedded in several 
ways in the client's life, they have built up over 
time, and they have often inscribed permanent 
social, emotional, and physical scars. Recovery 
from chronic, relapsing conditions takes time and 
requires much effort from an individual; how 
much the client wants to work toward recovery 
undoubtedly makes a difference in treatment. But 
people who seek drug treatment vary in what they 
want to gain and in who else is involved. For 
clients seeking admission, treatment is the solution 
to a problem or problems too serious to ignore and 
too large to handle without help. Full recovery 
from dependence, including complete abstinence 
from drug use, may not be necessary to solve the 
problem that led them to treatment, although it 
may be the answer, or part of the answer, to even 
larger problems that an individual seeking 
treatment does not acknowledge or yet want to 
solve. All of these elements affect how much 
effort the prospective client is willing to put into 
the recovery process. 

Drug treatment clinicians have devised ways to 
respond to these varying client features and have 
incorporated these methods into program policies 
and goals. Program policies are not all dry 
abstractions and pious sentiments; rather, they are 
rules of thumb for selecting clients for admission, 
dispensing discipline or extra attention, or deciding 
on discharge. Every program admits applicants to 
some degree according to its reading of an 
applicant's motives and situation, including the 
role of third parties such as the law and third-party 
payers. Programs vary in how eager they are to 
accept or avoid the harder cases, how intensively 
they are willing (or able) to work to treat the most 
difficult problem clients, and how heavily or 
swiftly or carefully they impose sanctions for 
noncompliance with the treatment plan. 



Abstinence from illicit drug consumption is the 
central clinical goal of every kind of drug 
treatment, but it is not the complete goal. 
Clinicians also want their clients to stay out of jail 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 4 



and away from criminal activities, to be physically 
healthy, to adopt productive roles in family or 
occupational settings, to feel comfortable and 
happy with themselves, to avoid abuse of or 
dependence on alcohol. Full recovery in all of 
these senses can be realistically envisioned in some 
fraction of cases—a fraction that depends in part on 
the kind of population from which the program 
recruits its clients. But full recovery is not a 
realistic goal for other individuals, and those 
others make up the majority of admissions to most 
drug programs. For another fraction of applicants, 
even partial recovery as a result of the particular 
treatment episode is unlikely, although a period in 
treatment may plant or nurture the seeds of more 
serious efforts toward treatment and recovery in 
the future. 

In summary, the pragmatic objectives of treatment 
in most cases are modest: to reduce illicit drug 
consumption, especially of the primary drug of 
abuse, by a large percentage— perhaps to nothing 
for an extended period—relative to the consumption 
one could expect in the absence of treatment; to 
reduce the intensity of other criminal activity if 
present; to permit the responsible fulfillment of 
family roles; to help raise employment or 
educational levels if the client so desires and the 
program has the resources available for such an 
effort; and to make the client less miserable and 
more comfortable physically and mentally. These 
goals are incremental: instead of absolute success 
and failure, there are degrees of improvement. 

In light of the substantial losses to society resulting 
from active drug abuse and dependence, the 
committee considers a quantitative reduction in 
illicit drug consumption and the problems that 
accompany it for an individual client to be a 
socially and personally valuable result. An 
extended abstinence, even if punctuated by slips 
and short relapses, is beneficial in itself and may 
serve as a critical intermediate step toward lifetime 
abstinence and recovery. A useful shorthand for 
this pragmatic goal is that drug treatment strives to 
initiate, accelerate, and help sustain the recovery 
process. 



Treatment goals may be influenced or guided by 
theoretical contemplation or rigorous induction, 
but they are typically selected and ordered by a 
complex process of social trial, error, and 
negotiation. Goals also vary because individual 
problems vary from client to client. Some clients' 
drug abuse or dependence is entangled in a chaotic 
life of violent criminal acts, ruptured family 
relationships, illiteracy, and psychological 
disturbance. For other individuals, drug abuse or 
dependence is a deviation from a pattern of 
conventional social successes and advantages. 
Treatment goals also vary because social concerns 
with different elements of drug problems differ 
over time and across institutional settings. 

Programs have different orientations that affect the 
kinds of clients they recruit and the depth of their 
commitment to the "total client." A program may 
be oriented primarily toward an intensive short- 
term (e.g., four- to six-week) treatment protocol, 
viewing its task only as ensuring that the first steps 
toward recovery are taken, leaving the client, 
family, and other interested parties to complete the 
recovery process. A program that for the most 
part recruits socially advantaged individuals will 
not need to provide or help the client find 
vocational, educational, housing, welfare, or 
primary medical services. 

A program with a longer term treatment protocol 
may view its primary responsibilities more 
comprehensively— to deal not only with the initial 
steps toward recovery but with any other aspects 
of the client's circumstances that may increase his 
or her vulnerability to relapse. If these negative 
circumstantial aspects are prominent, then that 
program sets itself a much more challenging task 
than the program whose clients have few problems 
other than drug-seeking behavior with which to 
contend. Often, a program must develop channels 
to vocational, educational, housing, welfare, 
psychiatric, or primary medical services or else 
gain the resources needed to offer the necessary 
services itself, particularly for clients who are so 
disorganized that they have to have everything 
packaged together in one place. Such programs 
are prepared to view joblessness, psychological 
depression, or homelessness as part of the 



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diagnosis they need to treat. That kind of 
perspective does not mean that these clinicians 
believe that joblessness, psychological depression, 
or homelessness are universal causes of drug 
problems or that the country must deal with 
unemployment, melancholy, and housing problems 
nationwide in order to help any individual client. 
It does, however, make these programs 
intrinsically more expensive to administer. The 
justification for the higher level of resources 
expended per client hinges on the prevailing norms 
surrounding assistance to the disadvantaged and the 
effectiveness with which programs are able to 
employ these resources to produce better recovery 
outcomes. 



CONCLUSION 



The picture of drug treatment goals that results 
from this chapter's analysis is not simple, but it 
has a certain coherence. That coherence resides in 
the principle that what should be expected from 
treatment is relative— relative to who is being 
treated and to how severe his or her problems are, 
and relative in that success should be viewed as a 
matter of more or less rather than all or none. 

To define a reasonable set of treatment goals, it is 
necessary to consider certain characteristics of 
those being treated: depth of drug dependence, 
extensiveness of criminal activity, state of physical 
health, history of employment, status of family 
support, what specific problem(s) precipitated 
treatment, who besides the individual client has 
become concerned with what he or she is doing, 
and the seriousness of the client's intentions. The 
goals of treatment are to address and significantly 
improve these characteristics; the effectiveness of 
treatment is gauged by how much it improves them 
compared with what would probably occur without 
treatment. 

In general, the primary goals of treatment have 
centered on reducing heroin or cocaine intake, 
predatory crime, and client death rates; at a 
secondary level, they involve marijuana or alcohol 
intake, unemployment or poor job performance, 



DEFINING THE GOALS OF TREATMENT 

and lack of education. Improving family 
conditions and psychological well-being are 
sometimes viewed as ends in themselves, at other 
times as side effects of reaching primary goals, 
and at still other times as important prerequisites 
to reaching primary goals. 

More is known about the primary than about the 
secondary issues. For example, predatory criminal 
behavior persists even in the teeth of extensive 
arrest and imprisonment. For this reason, criminal 
justice agencies have frequently turned to drug 
treatment programs for help in dealing with the 
drug-dependent criminals under their supervision 
in hopes of slowing down the increasing burden of 
recidivism and overcrowding. Employers, on the 
other hand, are much more committed to the use 
of drug testing, the most recent and rapidly 
growing employer program in this connection, to 
keep individuals with drug problems from entering 
the work force rather than to push toward recovery 
those who are already in it. This agenda may 
explain the fact that increasing drug treatment 
costs seem to them far more a threat to be 
eliminated than a productivity opportunity to be 
seized, an issue to which the committee turns in 
Chapter 8. 

Because recovery clearly is possible and because 
most people enter treatment in search of it, albeit 
under pressure and with very mixed and confused 
motives, the committee believes that any 
worthwhile treatment program or method should 
be able to demonstrate that it has accelerated 
recovery among most of its clientele. However, 
rapid and full recovery is sufficiently unusual 
outside of treatment that it should not be viewed as 
the sole measure of treatment success. Partial 
recovery is better than no recovery. There is a 
real difference between hundreds or thousands of 
illegal and unhealthy acts over a period of time 
and a handful or even scores of such acts, and that 
difference should not be ignored when programs 
are called on to account for their clients' behavior. 



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CHAPTER 5: THE EFFECTIVENESS OF TREA TMENT 



The question that people ask drug treatment 
experts most often and most insistently is a simple 
one: Does treatment really work? In the 
committee's judgment, and that of most experts, 
the available clinical experience and research data 
add up to a similarly short and pointed answer: It 
varies. This answer should be no surprise, as the 
question is naive. Virtually everything in Chapters 
2, 3, and 4 of this report leads one to expect the 
effectiveness of treatment to be a complicated 
matter to understand and assess. Drug treatment 
is not a single entity but a variety of different 
approaches to different populations and goals. 
Response to treatment is not a matter of all or 
nothing, complete success versus total failure, but 
of degrees of improvement. Moreover, the setting 
for evaluation is not the quiet purity of a 
controlled laboratory experiment but the tangled 
complexity of real lives and programs under 
pressure from many directions. 



How well does each modality work in 
practice? How adequate in terms of 
methodology are the evaluations of real 
programs, and what do the best of these 
evaluations reveal? 

If a modality is not working as well as 
might be expected, what are the 
reasons? For example, is the 
implementation or replication of the 
modality flawed or incomplete? Are the 
wrong kinds of clients being treated? 
Are there unexpected side effects? Does 
the environment interfere with the 
effectiveness of the treatment? 

Do the benefits of the treatment justify 
its costs? In other words, is treatment a 
sound investment of scarce public and/or 
private resources? 



The committee's strategy under the circumstances 
has been to put forward a line of questioning that 
is straightforward but somewhat more elaborate 
and revealing than "Does treatment really work?" 
These questions, which are listed below, cannot all 
be fully and confidently answered at present. 
Consequently, they must continue to be asked 
about each kind of treatment. 



What are the basic concepts or 
modalities of treatment? That is, what 
are the underlying designs or theories of 
treatment, what specific types of drug 
problems or population groups are being 
addressed by each design, and what are 
the best results that have been obtained 
under ideal conditions? 



In addition to these questions about 
treatment as it presently exists: How 
might JUrther research help to improve 
treatment? 



In responding to the first of these questions, this 
chapter considers serially the four major types or 
modalities of drug treatment: outpatient 

methadone maintenance, residential therapeutic 
communities (TCs), outpatient nonmethadone 
(OPNM) treatment, and inpatient/outpatient 
chemical dependency (CD) treatment. As 
indicated in the brief description of these 
modalities in Chapter 2, each type of drug 
treatment has developed since the 1950s. TCs 
derived largely from Synanon, which began in 
California in 1958. Methadone maintenance 
developed from studies on a hospital ward in New 
York in 1964; CD programs grew out of hospital 



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THE EFFECTIVENESS OF TREATMENT 



-based approaches to treating alcoholism in 
Minnesota in the 1960s. Outpatient nonmethadone 
treatment 1 goes back at least to psychoanalytic 
treatment of "toxicomania" in the 1930s, but the 
community mental health movement, youth crisis 
counseling, "drop-in centers," and "free clinics" of 
the 1960s adopted quite different orientations that 
have substantially shaped the OPNM programs 
seen today. Although every modality has specific 
roots, all have continued to evolve since their 
introduction. 

The most extensive usable results of research on 
the effectiveness of drug treatment are from 
several moderately sized clinical experiments and 
natural or quasi-experiments and from prospective 
longitudinal studies involving thousands of clients. 
There have been two large-scale, multisite, 
federally sponsored studies of publicly supported 
programs: the 12-year follow-up of a 1969-1971 
Drug Abuse Reporting Program (DARP) national 
admission sample cohort and the Treatment 
Outcome Prospective Study, or TOPS, which 
involved a 10,000-person national sample of 1979- 
1981 admissions to 41 drug treatment programs in 
10 cities. The Drug Abuse Treatment Outcome 
Study (DATOS), a third large-scale national 
prospective study, is scheduled to begin in 1990. 

The committee addresses the paradigmatic 
questions separately within each modality. 



1 Because methadone maintenance programs are virtually 
always conducted on an outpatient basis but are set apart by 
the specific reference to methadone, all other outpatient 
programs are conventionally lumped together as outpatient 
nonmethadone or outpatient drug free. In light of the frequent 
use of other psychotropic medications during outpatient 
treatment, the committee views the term "nonmethadone" as 
more accurate than "drug free." The lumping together of all 
outpatient nonmethadone treatment is testimony to the 
prominence and distinctive nature of methadone maintenance 
and the fact that the population it serves is sufficiently 
homogeneous and different from the populations served by 
other outpatient programs. It should also be noted that 
methadone may be used in modalities other than maintenance, 
which technically refers to a planned treatment duration of 1 80 
days or longer. (Shorter periods— usually 3 weeks to 2 months- 
-are considered methadone detoxification.) Planned methadone- 
to-abstinence tapers of longer than 180 days are also 
Incorporated into some program plans. 



Although many treatment seekers try more than 
one treatment modality over the course of their 
drug careers (they build up a "treatment career" as 
well), the average profiles of clients admitted to 
the major modalities are quite different. Both 
treatment seekers and treatment programs engage 
in a great deal of individual selection into which 
many factors enter. For example, programs are 
geographically and economically differentiated in 
their accessibility to various types of potential 
clients; methadone clinics are relatively low in cost 
and typically located in inner-city areas; chemical 
dependency units are generally expensive and 
found in affluent suburbs. The typical 

demographic and drug-taking patterns of the 
different modalities' populations (a reflection of 
who stays in treatment from among those who are 
admitted) are quite distinctive. As a result, one 
cannot simply compare the performance or results 
of each modality with the others as if their client 
populations were interchangeable. Moreover, 
because some clients move between programs and 
there is evidence that treatment effects may, in 
part, be delayed and cumulative, it is hazardous to 
ascribe all the effects of a treatment episode to that 
episode alone; adjustments must be made to take 
prior treatments into account. 

The most extensive and scientifically best 
developed evidence concerns methadone 
maintenance. A lower although still suggestive 
level of evidence is available concerning 
therapeutic communities and outpatient 
nonmethadone treatment. The lowest level of 
evidence is available for chemical dependency. 
Where the evidence on treatment effectiveness 
approaches adequacy, its overall tendencies are 
clear. 

■ Treatment reduces the drug consumption and 
other criminal behavior of a substantial 
number of people. Clients exhibit their best 
behavior while actively enrolled in 
treatment; their behavior is often poorer 
following treatment than during it, although 
still better than before admission. 



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■ There are large variations in effectiveness 
across programs, which seem to be related to 
the varying quality of clinical management 
and competence. Practices in methadone 
maintenance dosing are a clear instance of 
this variation; there is also variance owing to 
differences in the characteristics of the 
populations being treated, such as the 
severity of their problems at admission. 

■ The length of time in treatment is a very 
important correlate of outcome; that is, 
longer treatment episodes yield better 
outcomes than shorter ones. Retention is 
presumably related to general program 
quality and specific client motivation to 
remain in treatment; however, no predictive 
treatment motivation test is available, and the 
role of treatment in facilitating motivation or 
averting impulsive decisions to "split" from 
treatment is not yet well understood. 

■ The benefits of treatment programs on the 
whole outweigh their costs, but variations in 
cost-benefit methodologies and results are 
great. 

It should be noted that, except to describe the 
model, there are virtually no data to answer 
critical questions regarding independent self-help 
fellowship groups such as Narcotics Anonymous 
and Cocaine Anonymous or the Oxford Houses. 
Although the ideas underlying the Anonymous 
fellowships were incorporated at the outset into the 
clinical approaches 2 of TCs and CD programs and 
clients in these modalities are encouraged to 
participate in Anonymous meetings, the 
fellowships have shied away from involvement in 
formal evaluation protocols. Because drug-related 
Anonymous groups have been meeting in most 
cities longer than drug treatment programs have 

2 Although CD programs incorporate numerous therapeutic 
components in addition to Alcoholics Anonymous-type 
meetings, the 12 steps of the Anonymous creed are so 
fundamental to the CD modality that the latter has been 
referred to as the "professionalization of Alcoholics 
Anonymous." There is no scientific literature on the Oxford 
House approach, which combines residential proximity with the 
fellowship principles. 



been present, and because they generally welcome 
individuals who are in treatment as well as those 
who are not (except that many Anonymous groups 
are antipathetic to individuals in methadone 
maintenance), they are in essence a part of the 
environmental baseline over which the incremental 
effects of the more formal treatments must be 
measured. 

Two special topics are set slightly apart from the 
main lines of the chapter: the role of 
detoxification, which is often carried out in 
hospital settings, and the effects of treatment that 
occurs within correctional institutions. In the 
committee's view, it is not tenable to consider 
detoxification a treatment modality for the 
rehabilitation of drug abuse and dependence. 
Rather, it is a way of moderating some of the 
effects of overdose or withdrawal, and it may 
serve as a gateway to treatment. Correctional 
programs seem to fall largely into one of three 
types: they are either therapeutic communities, 
outpatient-type programs whose clients happen to 
live in prison, or drug law education programs 
carrying the name of treatment. 

The committee considers the need and opportunity 
for research relevant to treatment effectiveness to 
be so important that this chapter presents several 
recommendations for research on treatment 
methods and services. With recent budget 
increases for research, there is no overall lack of 
resources that could be devoted to such studies. 
Rather, the challenges of treatment-oriented 
research are arduous and demand certain kinds of 
commitments that are altogether too easy to slight 
in the rush to distribute cascades of research 
funding to more glamorous (e.g., high-technology) 
research ventures. 



METHADONE MAINTENANCE 
What Is Methadone Maintenance? 



Methadone maintenance is a treatment specifically 
designed for dependence on narcotic analgesics, 



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THE EFFECTIVENESS OF TREATMENT 



particularly the narcotic of greatest concern in the 
United States, heroin. 3 The controversies 
surrounding methadone maintenance 4 have made it 
the subject of literally hundreds of studies. From 
these studies, including a few vitally important 
clinical trials, strong evidence has accumulated 
about the safety and effectiveness of methadone. 

The idea is not unfamiliar that a treatment for a 
chronic health disorder could involve long-term, 
even permanent pharmacological maintenance 
using a powerful drug that is nevertheless safe if 
properly administered. Perhaps the most obvious 
examples are treatments for endocrine problems: 
insulin for diabetes, thyroxin for thyroid 



*There are three main types of narcotic analgesics: those 
derived from opium, such as morphine, heroin 
(diacetylmorphine), and codeine, and the two major synthetics, 
meperidine (best known as Demerol) and methadone. There 
are numerous congeners of each major narcotic type that have 
varying degrees of activity. The natural and synthetic 
compounds have dissimilar chemical bases but share certain 
critical structural properties that result in their penetrating and 
affecting the "endogenous opioid" neurotransmitter system in 
similar ways. There are significant differences, however, in 
how the major narcotic types are absorbed and metabolized 
outside the brain; these difference affect the duration and rate 
of their central nervous system effects. 

'There continue to be widespread negative beliefs among the 
general public and some policymakers about methadone (see, 
for example, the results of focus group discussions reported by 
the Technical Assistance & Training Corporation [1989]). The 
drug is suspected, for example, of being unsafe even in 
clinically controlled usage; it is said to "rot" the bones (or the 
brain, or the liver) and to create lassitude or stupefaction 
among individuals who take it for any length of time or at any 
dose except a minimal one. It is also said that indefinite 
maintenance is "just substituting one addiction for another," so 
the most important clinical goal should be to "get off 
methadone" as soon as possible. It is thought that most of the 
people enrolled in methadone maintenance programs sell some 
or all of their daily methadone dose and use the proceeds to 
buy heroin and other drugs. Putting all of these beliefs 
together, methadone can be portrayed as an assault on the 
well-being of communities in which methadone maintenance 
clinics are located, rather than a therapeutic response to local 
drug problems. 

This set of beliefs about methadone is based partly on shards 
of experience (often reported by journalists), partly on 
philosophical or ideological premises that may be impervious to 
evidence, and partly on frank skepticism about the existence of 
a therapeutic rationale or base of evidence underpinning 
methadone maintenance treatment. This section should at 
least be useful in addressing the last of these sources of belief. 



deficiency. A treatment for chronic mood 
disorders (manic-depressive cyclothymia) using 
lithium chloride for long-term maintenance is a 
psychiatric example. Although methadone 

maintenance was viewed as revolutionary when it 
was first developed in the United States, the 
historical sketches in Chapter 2 and in Courtwright 
(1992) point toward early twentieth century 
instances in U.S. cities of morphine maintenance 
as a treatment for opiate dependence. In Great 
Britain, heroin maintenance was also practiced, 
although it has largely been replaced there by 
methadone maintenance. The application of 
maintenance concepts to the treatment of drug 
dependence therefore is not medically unusual. 
But to understand how methadone maintenance 
operates as a treatment for heroin dependence, 
three aspects must be stressed: the significance of 
clinically defined goals, the pharmacological basis 
of drug substitution, and the embedding of 
substitution in a broader clinical-behavioral 
strategy. 



Goals 

Methadone maintenance cannot be understood 
apart from the correct stipulation of the major 
goals of treatment, primarily to reduce illicit drug 
consumption and other criminal behavior and 
secondarily to improve productive social behavior 
and psychological well-being. It is critical that 
methadone is a legally prescribed drug for the 
purpose of treating dependence. 5 Yet even more 
critical is that individuals who receive methadone 
maintenance treatment should reduce their use of 
illicit drugs and their commission of other crimes 
(e.g., selling drugs, stealing money, using 
weapons to obtain funds to support their drug 
consumption) ideally to zero but at least by an 
appreciable amount. Improved social productivity 
and well-being would be important further 
measures of the effectiveness of methadone 

'The argument has been made that even illegally marketed 
methadone represents a significant public health improvement 
over street heroin. Although this result is theoretically 
plausible, an opposite result is equally plausible, and there is 
little evidence to support either theory. Therefore, In policy 
terms, street methadone sales are a negative effect. 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



maintenance. The goal of ending the licit 
dependence on methadone itself is well down the 
list— so that the risk of increased crime or illicit 
drug use weighs heavily against arbitrary limitation 
on the duration of methadone maintenance. 
Nevertheless, this goal has been given much 
higher priority in many programs, as discussed 
later in the chapter. 



Substitution 



At the base of methadone maintenance is an 
empirical observation that was made before the 
biological reasons for it were well understood: all 
of the effective narcotic analgesics may be 
substituted for one another with adjustments in 
dose and route of administration. Substitution is 
possible because there are basic similarities in their 
objective and subjective effects; in particular, in 
dependent individuals there is parallel or cross- 
tolerance to elevated doses and cross-suppression 
of respective withdrawal effects. Key differences 
involve how quick, how strong, and how long- 
lasting these actions are; they are also apparent in 
the precise mixture of effects for each drug. 

Cross-dependence is particularly important in 
detoxification. Most drugs of widespread abuse 
and dependence (heroin, cocaine, alcohol) act 
quickly and dramatically and wear off in a matter 
of hours. By the same token, the associated 
primary withdrawal syndromes tend to be striking 
but short; there is usually, however, a somewhat 
more protracted but less dramatic phase of 
sustained withdrawal symptoms such as sleep 
disturbance, agitation, or mild depression. The 
general approach to detoxification is to moderate 
the more severe symptoms, often by substituting a 
long-acting drug, which can then be tapered down 
to zero, leaving only the lesser symptoms. 

Methadone may be prescribed not for maintenance 
purposes but for a shorter period—three weeks was 
once standard, although the period may legally 
extend up to six months— to moderate withdrawal 
symptoms. Detoxification generally begins with 



an escalating dosage to reach a point such that the 
patient stops using other opiates, and withdrawal 
symptoms are not evident. Then the methadone 
dose is tapered down to zero. Individual responses 
vary, but usually this method does not completely 
suppress withdrawal symptoms during and after the 
tapering period; rather, it keeps them mild for a 
time— until the tapering procedure does not provide 
enough methadone to prevent the more 
discomfiting withdrawal symptoms. It is common 
for individuals to drop out of methadone 
detoxification some time during the second week 
of a typical three-week planned detoxification 
period. Sometimes other medications are given 
during methadone detoxification to manage 
particular symptoms. 

As shown by the long record of experience with 
detoxification of heroin dependence, those 
detoxified were universally found to have a very 
high susceptibility to relapse— usually well in 
excess of 90 percent of followed cases (see 
Vaillant, 1973). After detoxification, and often 
before its procedures had been completed, there 
was a resumption of craving for opiates. Dole 
(1988) and others have theorized that the extensive 
use of opiates may bring on alterations in the brain 
neurotransmitter/receptor systems affected by 
opiates, leaving many individuals with a virtually 
permanent craving that can only be assuaged by 
drugs of the opiate family. 

Methadone has several unusual pharmacological 
properties that have made it especially suited to a 
maintenance approach. Unlike many opiates, it is 
effective orally, a significant advantage in that oral 
dosing is more hygienic than the needle and more 
easily titrated than smoke. Because of 

methadone's particular pattern of absorption, 
metabolism, and elimination, a single dose within 
a train of level doses, in the typical maintenance 
range of 30 to 100 milligrams per day (mg/day), 
takes effect gradually and wears off slowly, 
yielding a fairly even effect across a period of 24 
hours or longer. Methadone is thus conducive to 
a regime of single daily maintenance doses, 
eliminating dramatic subjective or behavioral 
changes and making it easy for clinician and client 



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THE EFFECTIVENESS OF TREATMENT 



to fit into a routinized clinic schedule. 6 This 
pattern is very different from the shorter action 
and more dramatic highs and lows of heroin, 
morphine, and most other opiates. The long-term 
toxic side effects of methadone, as of other opiates 
if taken in hygienic conditions in controlled doses, 
are notably benign. 

The short-term clinical effects of methadone were 
first studied at the Lexington addiction research 
center in the 1950s, and research continued there 
and elsewhere into the 1960s. Since the mid- 
1960s, about 1.5 million person-years of 
methadone maintenance have accumulated in the 
United States. Not all clients have been closely 
observed for medical side effects, but the 
thousands of research cases that have been 
carefully observed yield a well-documented 
conclusion: 



to methadone during chronic treatment is 
extraordinarily rare. The most important 
medical consequence of methadone during 
chronic treatment, in fact, is the marked 
improvement in general health and 
nutritional status observed in patients as 
compared with their status at the time of 
admission to treatment. (Kreek, 1983:474) 



The most common physical complaints during 
methadone maintenance are insomnia and weight 
gain, but these are clinically related both to the 
consumption of other drugs and alcohol 
(consumption that continues and sometimes 
increases among a fraction of clients, the size of 
which varies from program to program) and to 
preexisting or coexisting abnormalities common in 
this population and in the general population. 



[PJhysiological and biochemical 
alterations occur, but there are minimal 
side effects that are clinically detectable 
in patients during chronic methadone 
maintenance treatment. Toxicity related 



"There was extensive research from the late 1960s to the late 
1970s on a longer acting methadone congener, levo-alpha- 
acetylmethadyl (LAAM), that requires less frequent doses- 
every two or three days instead of daily. LAAM has been 
studied in a series of phased clinical trials but has not yet been 
approved for nonexperimental use, although its safety and 
freedom from toxic side effects appear comparable to those of 
methadone (Savage et al., 1 976; Ling et al., 1 978; Blaine et al. 
1981). Overall, during the trials, methadone was more 
successful than LAAM in retaining clients in treatment (by 20 
percentage points), largely because more LAAM recipients felt 
that the medication was not "holding," that is, not keeping 
opiate withdrawal symptoms from beginning to emerge 
between doses, a result that Goldstein and Judson (1974), 
after a double-blind study, judged to be more psychological 
than physiological in origin. LAAM recipients who stayed in 
treatment used less heroin and performed better on other 
clinical measures than methadone clients, particularly those on 
lower methadone doses. Some clinicians reported a 
substantially improved therapeutic climate in LAAM clinics 
owing to the more relaxed three-days-per-week visiting 
schedule (Goldstein, 1976). There are probably clients who 
would do better on LAAM than on methadone, and vice versa, 
with results for both likely to improve with better dose 
optimization and counseling about differences between the two 
drugs. A revival of interest in LAAM and an attempt to restore 
the initiative toward approval by the Food and Drug 
Administration for nonexperimental use are under way. 



Clinical Behavioral Strategy 



In terms of the social history and individual model 
of drug-seeking behavior reviewed in Chapters 2 
and 3, a program of controlled methadone 
maintenance at an appropriate dose level could 
have recovery-inducing effects on heroin 
dependence. These effects may be felt through 
two paths corresponding to the two most common 
motivational processes that operate during heroin 
dependence: pleasure seeking and withdrawal 
avoidance. 

With regard to pleasure seeking, methadone is an 
effective analgesic. Yet the effect of an 
accustomed (tolerated) dose is merely a dim echo 
or reminder of heroin's most intense effects, not so 
much a "rush" as a reassurance— which may wear 
better in the long run and is certainly less 
disruptive in the short run than the euphoric heroin 
high with its associated itchiness and dreamy nods. 
There is also a more subtle and perhaps equally 
valuable effect: if heroin and methadone are both 
in the body, their active metabolites compete with 
each other for access to sites of action in the brain. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



If the methadone dose is high relative to the heroin 
dose, the latter will not have a very distinctive 
effect, and the individual taking methadone will 
find heroin less rewarding. As a result, the 
shooting of heroin "over" the methadone may 
become self-extinguishing. 

On the other side of the pharmacological fence, 
methadone maintenance prevents symptoms of 
heroin withdrawal, which, although not life- 
threatening or excruciating, are immiserating (a 
good parallel is a head cold or a bout of 
influenza). The critical condition is that the 
dependent person feeling withdrawal symptoms 
knows that all of these unwelcome sensations can 
be banished within minutes with a dose of an 
opiate. Recurrent withdrawal symptoms stimulate 
drug seeking during heroin dependence, and the 
ability of methadone maintenance to keep them at 
bay is a major attraction and benefit. 

In its initial clinical trials, which began in inpatient 
settings and then were extended to outpatient sites, 
methadone maintenance proved capable of 
stabilizing the psychological functioning of the 
heroin-dependent individual at a near normal state. 
Methadone in effect eliminated the alternating 
phases of euphoria, somnolence, and agitated 
concern characteristic of the incipient stage of 
withdrawal from heroin dependence. The 
clinicians conducting the trials observed that 
clients on methadone were not obsessed with 
acquiring the next dose, became interested in the 
prospects for improving the conventional strands 
of their lives, and were generally functioning 
without notable drug impairment or side effects. 
An individual on methadone was capable of 
participating in counseling, psychotherapy, and 
remedial education and training (most of the same 
rehabilitative services delivered in therapeutic 
communities and outpatient treatment). This 
capability was partly the result of the intrinsic 
pharmacological effects of methadone and partly 
because, unlike street heroin, it was provided 
reliably, in legitimate clinical settings, and in 
reliable doses. 



Methadone maintenance was originally defined as 
the administration of methadone together with 
rehabilitative and counseling services, and this 
definition, along with many detailed specifications 
about facilities and staffing, was built into federal 
regulations as a required protocol for a licensed 
methadone maintenance program. These 

regulations permit methadone to be dispensed only 
by licensed maintenance or detoxification programs 
or by hospital pharmacies. (In hospitals, 
methadone is prescribed mainly for severe 
postoperative or cancer pain and occasionally for 
short-term inpatient detoxification.) 

Methadone programs are nearly always 
ambulatory, with daily visits to swallow the 
methadone dose (usually provided in a 3- to 4- 
ounce plastic bottle of sweetened, orange-flavored 
water) in the clinic, except for the traditional 
Sunday take-home dose. After several months in 
the program with a "clean" drug-testing record and 
good compliance with other program requirements 
such as counseling appointments, clients may 
regularly take home one or more days' doses 
between every-other-day, twice- weekly, or even 
weekly visits—a revocable range of privileges. 
Some methadone clients voluntarily reduce their 
doses to abstinence and conclude treatment after 
some time; others remain on methadone 
indefinitely. 

The role of counseling is multifold. In the first 
instance, the design of methadone maintenance 
programs includes numerous monitoring and 
adjustment features that stress the need for clients 
to wean themselves away from street drug seeking. 
Program clinics have specific hours for dispensing, 
counseling, and medical appointments; there are 
codes of proscribed behavior (e.g., no violence or 
threats of violence), and monitored drug tests are 
conducted at random intervals— at least monthly 
and as often as weekly, although the cost of the 
tests have led financially strained programs to cut 
them back to the minimum. Counseling includes 
the assessment of client attitudes and appearance 
(important in themselves and as clues to drug 
behavior) and the gathering of information about 
employment, family, and criminal activities; 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



THE EFFECTIVENESS OF TREATMENT 



counselors offer psychotherapy and individualized 
social assistance and recognition, depending on 
their caseloads and their training for such tasks. 

In most clinics, counselors participate in staff 
decisions with regard to changing dose levels, 
requirements for therapeutic contacts, award and 
revocation of take-home privileges, and decisions 
regarding termination from the program. Clinical 
experiments have studied methadone dosage and 
behavioral techniques (contingent rewards and 
sanctions for "dirty" urines and missed and late 
counseling appointments) as part of the modality's 
repertoire. The clinical trial literature has 
demonstrated important success in the use of 
methadone dosage supplements or decrements and 
take-home privileges to punish or reward clients 
for noncompliance with such clinical rules as the 
proscription on continued drug use and the 
requirement of cooperation by timely attendance 
for dispersing, participating in counseling, and 
paying required fees (Stitzer et al., 1983). 

The drawbacks to methadone maintenance have 
been well recognized since its inception: the client 
is still at least mildly dependent; the drug reduces 
heroin craving and stabilizes the individual 
psychologically but does not necessarily modify or 
rehabilitate other behavior; clients often still use or 
abuse and sometimes become dependent on other 
drugs including alcohol; and it is possible for take- 
home methadone to be diverted from therapeutic 
uses and sold to permit the client to buy heroin or 
other drugs. Moreover, methadone has no direct 
pharmacological bearing on abuse or dependence 
on alcohol or other drugs, especially cocaine, 
which has become such a serious and widespread 
problem in the 1980s. The important question is 
this: Does the modality reach its primary goals in 
enough cases to outweigh these limitations and 
drawbacks? 



How Well Does Methadone Work? 

The goals of methadone maintenance— to reduce 
illicit consumption of heroin and other opiates, to 
reduce other criminal activity, and to help clients 



become more socially productive and 
psychologically stable— constitute a continuum that 
can be cut at various points to designate "success" 
versus "failure." At the outset of its use, the 
modality was specifically targeted toward those 
who were most severely dependent, as judged by 
substantial histories of relapse from earlier 
detoxification episodes (frequently in jail); this 
commitment was built into the early regulations 
requiring documentation of at least two years of 
heroin use and two prior relapses. 

Early trials of methadone maintenance in New 
York (Dole and Nyswander, 1965, 1967; Dole et 
al., 1966, 1968, 1969) noted two striking findings: 
the majority of clients would remain in treatment 
for as long as it was available to them, in 
substantial contrast to the usual experience in 
outpatient psychotherapy; and methadone 
maintenance significantly improved the condition 
of clients as revealed by studies that considered 
behavior in the community for periods of several 
months to several years. Although there was some 
use of other drugs, including heroin, especially in 
the first few weeks after admission, such use 
generally fell off over time, contrasting sharply 
with the increasing return over time to heroin 
dependence that was the norm after detoxification 
or other typical medical or psychiatric treatments. 
The steadiness of employment increased 
somewhat, but a much more dramatic change was 
the sustained reduction in criminal behavior, 
especially drug trafficking crimes. 7 

The most convincing results about the efficacy of 
methadone maintenance— the capacity of the 
treatment to induce client changes independent of 
initial selection or motivational effects— come from 



'Observational studies of the original Dole-Nys wander program 
cohorts, which probably engaged the most highly motivated 
clients and had relatively high-quality staff and resources, 
yielded good data over time confirming the long-term efficacy 
of methadone maintenance (Dole et al., 1968; Gearing, 1970, 
1974; Dole and Joseph, 1978). Studies in these and later 
programs also indicated the close relation of retention in 
treatment and good outcomes; attrition after a short period in 
treatment was associated with higher rates of relapse (Simpson 
et al., 1979; Hubbard et al., 1989). 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



a handful of clinical experiments that are widely 
separated in time and place but that consistently 
yield very distinctive findings. In these studies, 
heroin-dependent, heavily criminally involved 
populations who were randomly assigned to 
methadone maintenance or a control condition (an 
outpatient nonmethadone modality) demonstrated 
clinically important and statistically significant 
differences in favor of methadone on the gauges of 
drug use, criminal activity, and engagement in 
socially productive roles such as employment, 
education, or responsible child rearing. 

In the landmark experiment, Dole and colleagues 
(1969) randomly assigned 32 well-motivated 
criminal addicts to either a methadone treatment 
group (N = 16, of whom 4 declined treatment 
before program initiation) or a year-long 
control/ waiting list group (N = 16). Out of the 
combined control and refuser group (N = 16 + 4 
= 20), every individual became re-addicted to 
heroin soon after release, with 18 individuals 
returning to jail and the other 2 being lost to the 
study. At 7 to 10 months after initiation of the 
study, only 3 of the 12 addicts in the experimental 
group had been reincarcerated. Furthermore, 
although 10 of these 12 individuals had used 
heroin since the program was initiated, for 6 of the 
10 this use was limited to the first 3 months of the 
program. 

Gunne and Gronbladh (1984) have also reported a 
small but persuasive study (Figure 5-1). Thirty- 
four heroin-dependent individuals applied for 
admission to the only methadone clinic in a 
Swedish community; 17 were randomly assigned 
to methadone maintenance, and 17 were assigned 
to outpatient nonmethadone treatment (these 
individuals could not apply for admission to the 
methadone clinic again for 24 months). Two years 
later, 12 of the 17 clients on methadone were no 
longer using illicit drugs; 10 were employed, and 
2 were in school. Five still had drug problems, 
and of these, 2 had been discharged from 
treatment for severe abuse of sedative-hypnotic 
drugs. Of the 17 individuals who went into the 
outpatient nonmethadone program, only 1 was 
doing well; 2 were dead, 2 were in prison, and the 



rest had returned to taking heroin. After two 
years, then, 71 percent of methadone clients were 
doing well, compared with 6 percent of controls. 
Five years after the study began, 13 of the 
methadone clients remained in treatment and were 
still not using heroin, and 4 had been excluded 
from treatment because of unremitting drug 
problems. Among the controls, 9 had applied for 
and entered methadone maintenance; of these, 8 
individuals were not using drugs and were socially 
productive. Of the 8 controls who did not apply 
for methadone when eligible, "five are dead 
(allegedly from overdose), two in prison and one 
is still drug free" (Gunne and Gronbladh, 
1984:21 1). 8 

Another perspective on the effectiveness of 
methadone treatment is offered by the results of 
several "natural experiments." In one such study, 
McGlothlin and Anglin (1984) examined the 
introduction of the methadone maintenance 
modality to California in 1971, viewing it as a 



8 One other significant experimental study was reported by 
Newman and Whitehill (1978) from Hong Kong. This study 
demonstrated both the attractiveness or retentive power of 
methadone as such and the difficulties of conducting 
randomized clinical trials with drug-dependent populations 
when they are able to act on their own strong preferences 
about treatment assignment. (Another illustration of that 
difficulty in the United States was reported by Bale and 
coworkers [1980].) Newman and Whitehill studied 100 male 
heroin addicts who were seeking methadone maintenance. The 
men were hospitalized for one week and stabilized on 60 
mg/day of methadone. They were then randomly assigned to 
ambulatory methadone maintenance or to slow detoxification. 
The maintenance group started out at 60 mg/day and ended by 
averaging 97 mg/day. The detoxification group was taken 
down 1 mg/day over 60 days, after which they were given 
placebos. The medication was given on a double-blind basis: 
neither patients nor clinicians had certain knowledge of which 
group they were in. 

About 60 percent of maintenance patients were retained in 
treatment for the entire 2.5-year trial period, a rate 
commensurate with retention studies in the United States. In 
contrast, the patients who were detoxified dropped out of 
treatment rapidly. By the time they reached the placebo state, 
only 20 percent remained in treatment; nearly all had dropped 
out by the end of a year. Dropouts from the control group 
were subsequently recruited into methadone maintenance and 
had the same retention rates from that point on as the original 
maintenance group. Most of the control group sensed that 
they were being detoxified rather than maintained, and many 
quit the study to reenroll in methadone maintenance. 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



THE EFFECTIVENESS OF TREATMENT 



quasi-experimental intervention. They had 
previously begun a long-term observational study 
of heroin-dependent individuals who had been 
apprehended by law enforcement agencies in 1961- 
1963 (McGlothlin et al., 1977). Drug 

consumption and criminal involvement in this 
study population were high just prior to the 
introduction of methadone, despite the fact that all 
members of the population had been incarcerated 
and supervised for several years in the 1960s by 
the state's Civil Addict Program (CAP). Some of 
the study population had already stopped using 
heroin before the introduction of methadone; this 
group was termed the inactive user sample. Some 
of the remainder entered methadone treatment 
when it became available (the methadone sample), 
and the rest did not (the active user sample; 
Figures 5-2a, 5-2b, and 5-2c). McGlothlin and 
colleagues (1977) had found during their earlier 
study that the active user and methadone samples 
had reduced drug and crime activity while under 
CAP supervision but had quickly resumed their 
prior high activity levels once CAP supervision 
ended. After the advent of methadone programs in 
California, a major difference was observed 
between those in the active user group and the 
methadone clients, a difference that persisted for at 
least three years after the introduction of 
methadone. 

Overall, the findings of this natural experiment 
indicate that a certain proportion of addicts (i.e., 
the inactive sample) had responded favorably and 
permanently to a particular form of criminal justice 
supervision involving specialized prison treatment 
and intensive parole. Of those who did not, a 
significant proportion entered methadone 
maintenance when it became available and 
responded very well to it (compared with 
otherwise very similar individuals who did not 
enter a methadone program): those pursuing 
methadone maintenance substantially reduced their 
drug use and criminal activity and (to a lesser 
degree) increased their employment. 

Similar results have been reported in natural 
experiments involving the limited introduction of 
publicly supported methadone maintenance 



programs in a number of California cities and 
towns in the early 1970s and the subsequent 
closure of some of these programs for fiscal and 
political reasons. In cities where methadone 
maintenance became much less accessible as a 
result of such closures, former clients as a whole 
did appreciably less well at the two-year follow-up 
(in terms of heroin use, other criminal behavior, 
and, to a lesser degree, employment) than 
comparison groups in locations where there was 
continued access to treatment. In cities where 
public programs closed but private ones opened, 
those who transferred to the alternative methadone 
maintenance programs did much better (in terms of 
staying free of drugs and out of crime) than those 
who did not or could not continue treatment 
(McGlothlin and Anglin, 1981; Anglin et al., 
1989a). In these as in all other studies, longer 
retention in methadone as opposed to early attrition 
from the program was associated with much better 
results measured by reduced heroin use and other 
criminal activity. 



Why Do the Results of 
Methadone Treatment Vary? 

A significant proportion of methadone maintenance 
clients do not respond well to treatment, for a 
variety of reasons relating to the clients themselves 
and to the programs. This proportion averages 
about one in four, although there is wide variation 
from program to program (U.S. General 
Accounting Office, 1990; Ball et al., 1988). It is 
clear that some clients who are admitted enter 
methadone maintenance for purposes other than to 
receive counseling and other services or to pursue 
recovery. These clients are not compliant with 
clinical rules and are less likely than others to be 
(or become) motivated; most leave treatment after 
short periods. It is much easier to identify these 
clients after the fact than before; programs screen 
out some but not all such clients through 
pretreatment intake reviews. There are also 
probably some clients who would recover just as 
quickly without methadone maintenance, but they 
choose methadone treatment because it is helpful 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



109 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1. CHAPTER S 



BEFORE 



Experimental group 
(methadone) 



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Control group 
(no methadone) 



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AFTER 2 YEARS 



Experimental group 
(methadone) 

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XX ® ® 
® 



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(no methadone) 

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AFTER 5 YEARS 



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f 







FIGURE 5-1 Clinical trial of methadone maintenance versus outpatient nonmethadone for heroin 
addiction conducted through the Swedish Methadone Maintenance Program. 

Sourca: GuniM and Gronbladh (1984). 



110 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



THE EFFECTIVENESS OF TREATMENT 




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14 13 12 11 10 9 8 7 6 5 4 3 2 1 M 1 2 3 



YEARS BEFORE 
METHADONE ADMISSION 



YEARS 
AFTER 



—— Penod of CAP Commitment 

X* Penod of U.S. Heroin Epidemic 

FIGURES 5-2 Effects of methadone maintenance in a sample of California ex-parolees 
who participated in the Civil Addict Program (CAP) measured on three parameters: 

(a) percentage of time reported as dally narcotic use; lb) percentage of nonlncarcerated time spent In criminal activity; and (c) percentage 
of nonlncarcerated time the Individual was employed. CAP clients were divided Into three groups: Inactive users, active users, and 
methadone recipients. Source: Anglln and McGlothlin (1984). 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



or attractive in some ways that other treatments (or 
no treatment) are not. The proportion of such 
clients is variable—it may be as low as 1 in 20 or 
as high as 1 in 10. These clients are beneficial in 
terms of positive program statistics but somewhat 
exaggerate the degree to which the program is 
actually generating worthwhile effects. 

The largest group of clients is clearly at some 
point in the middle. The evidence from 
experimental and quasi-experimental studies clearly 
points toward the existence of a substantial number 
of heroin-dependent individuals who perform at 
least moderately well in response to methadone 
maintenance and who would do poorly without it, 
even when other kinds of treatment are available. 

There is compelling evidence that program factors 
such as methadone dosing policies and counselor 
characteristics affect the behavior of such 
relatively malleable clients above and beyond any 
initial differences in motivation. The strongest 
treatment retention and outcomes (measured as 
improved social functioning) were seen in the 
initial methadone clinical trials (Dole and 
Nys wander, 1965, 1967) and in cohorts admitted 
to methadone treatment in New York during the 
pilot stage of developing the treatment (Gearing, 
1970, 1974). This phase of history was 
characterized by careful screening of clients, self- 
selection by addicts—as a result of admission 
waiting lists of up to a year— and extensive 
adjunctive services provided by highly skilled and 
motivated clinical staff (Lukoff and Kleiman, 
1977). 

Later evaluations found that retention rates and 
outcomes were somewhat poorer when the New 
York programs had reached large-scale operation, 
were no longer highly selective in admissions, and 
had reduced their waiting time for admission to a 
few weeks (Dole, 1971; Dole and Nyswander, 
1976; Dole and Joseph, 1978). Some observers 
attributed this decline to strains on system capacity 
and the onset of rigid and antipathetic federal 
regulations in contravention of good clinical 
practices (Dole and Nyswander, 1976). Kleber 
(1977:268) has contended that the programs' 



primary problems were greatly reduced 
selectiveness in admissions and the shortage of 
skilled and motivated staff: "it is not surprising 
that retention rates dropped and the number of 
urines containing heroin rose. What is surprising 
is that the figures were not worse than they were. " 

Program performance (in terms of client retention 
and continued use of drugs) has also been observed 
to vary across programs at the same point in time. 
The Treatment Outcome Prospective Study, for 
example, showed a large degree of variation in 
clinically important client outcomes across nine 
methadone maintenance programs. Twelve-month 
retention rates averaged 34 percent of admissions, 
but five programs had low rates of 7 to 25 percent, 
whereas two programs had rates greater than 50 
percent. Regular heroin use by clients at follow- 
up (approximately three years later) was reported 
by 21 percent of the entire follow-up sample, but 
two programs had rates greater than 30 percent, 
and three had rates of 11 to 14 percent (Hubbard 
et al., 1989). 

Variation in performance has been linked most 
strongly to variations in methadone dosage 
policies. Programs that are committed to 
maintaining low average doses (30-50 mg/day) as 
a virtual goal of treatment— because of therapeutic 
philosophy or because state regulators strongly 
discourage higher doses— are less tolerant of 
occasional client drug use, missed counseling 
appointments, and other such treatment lapses, and 
have markedly lower client retention rates than 
more tolerant higher dosage programs. This lower 
tolerance does not, however, act as a stimulant to 
better client behavior or as a conveyor to move 
poorly responding clients out and bring in or keep 
better ones. There is solid, experimentally 
grounded evidence (see the major review by 
Hargreaves, 1983, and the associated conclusions 
of the expert consensus conference; reported in 
Cooper et al., 1983) that higher dose levels are 
fundamentally more successful in controlling a 
client's illicit drug consumption while he or she is 
in treatment. Although dose levels must 
necessarily be adjusted according to individual 
variations in metabolism and size, programs that 



112 



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THE EFFECTIVENESS OF TREA TMENT 



maintain an overall average dose of 60-100 mg/day 
yield consistently better results than those 
averaging less. Doses in excess of 120 mg/day are 
seldom needed. 

The most recent illustration of the importance of 
dose levels— and the fact that many programs 
continue to be committed to low-dose regimes in 
spite of strong evidence against their relative 
effectiveness—comes from a study reported by Ball 
and coworkers (Ball et al., 1988; Ball, 1989; see 
also Dole, 1989). Dramatic differences in client 
use of opiates and retention in treatment were 
found among six methadone clinics in three eastern 
cities studied in 1985-1986 and selected to begin 
with as well-regarded programs. In the best clinic, 
urinalysis revealed that 10 percent of enrolled 
clients in the sample had used drugs intravenously 
in the month prior to the one-year follow-up. In 
the two worst clinics, more than 55 percent of 
clients had used intravenous drugs in the previous 
month. 

Discriminant function analysis found that the most 
important factor in predicting intravenous drug use 
was the methadone dose level (Table 5-1). 
Among clients in treatment from 6 months to 4.5 
years the odds of recent heroin consumption 
decreased at each higher level of methadone. 
There was also a dose-related decrease in the 
chances of cocaine use, although the gradient was 
less steep. (This trend probably has little direct 
pharmacological cause but instead arises from the 
generalized behaviors of drug marketing and drug 
seeking: those who are actively seeking heroin are 
more likely to seek out or at least happen upon 
cocaine while doing so, and vice versa.) The 
programs with the highest illicit drug consumption 
among clients not only had low methadone doses 
but also had high rates of staff turnover and poor 
relationships between staff and clients. Knowledge 
of and sensitivity to the clinical significance of 
appropriate dose levels is probably one sizable 
element in a constellation of clinical competencies 
and strategies that contribute to the greater or 
lesser effectiveness of methadone maintenance 
programs. There are only rudiments of standards 
for training, credentialing, continuing education, 



evaluation, and clinical performance of counselors 
and other treatment program staff. It is 
remarkable how few research efforts have focused 
on this larger area of competence, appropriate 
training, and different service arrangements in the 
clinical management of methadone clients. A 
serendipitous experimental study by McLellan and 
colleagues (1988), which demonstrated striking 
differences in counselor effectiveness within the 
framework of a large, stable, well-regarded 
methadone maintenance program, 9 is a lonely 
beacon in the literature. 

Costs and Benefits of Methadone Treatment 

Analyses of the economic costs and benefits of 
methadone maintenance have been derived from a 
handful of treatment effectiveness studies, and 
their results are rather sensitive to how these 
effectiveness studies are interpreted. An early 
simulation by Maidlow and Berman (1972), for 
example, concluded that methadone maintenance 
could yield lifetime benefits to society of $348,000 
compared with average treatment costs of $13,200, 
a benefit/ cost ratio of 26 to 1 . However, their 
assumptions about the effectiveness of methadone 
were overly optimistic. A simulation by Rufener 
and colleagues (1977a) was more firmly grounded, 
yielding a smaller but still quite healthy 
benefit/ cost ratio of 4.4 to 1 for a short period of 
time. Extended over lifetimes this result would 
not be too disparate with that of Maidlow and 
Berman; however, the Rufener team's assumptions 
about effectiveness also appear to be too 
optimistic. 10 

9 Only four counselors participated in the McLellan study. 
10 Rufener and coworkers (1977a) examined the cost- 
effectiveness of three major treatment modalities (methadone 
maintenance, TCs, and outpatient nonmethadone) based on an 
analysis of the DARP data base (Sells, 1974a, b). Methadone 
maintenance was decidedly the most cost-effective treatment 
in terms of lowest cost per opiate-free days, non-opiate-free 
days, days not spent in criminal activity, and legitimately 
employed days. Goldschmidt (1976) similarly compared 
methadone maintenance and therapeutic communities, but his 
effort identified the benefits of both the in-treatment and 
posttreatment periods. He concluded that methadone and 
therapeutic communities produced similar "effectiveness units" 
(percentage of addicts meeting success criteria). The cost 
advantage of methadone, however, made its cost-effectiveness 
about twice that of therapeutic communities. 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1. CHAPTER 5 



TABLE 5.1 Heroin or Cocaine Consumption of 338 Methadone Clients (in treatment 
from 6 months to 4.5 years) in Past 30 Days By Methadone Dose 









Percentage Who Used Drug Within Past 30 Days 




No 


No Heroin 


Any 


Any 


Dose (mg/day) 


N 


% 


Heroin 


or Cocaine 


Heroin 


Cocaine 


0-39 


105 


100 


69 


57 


31 


29 


40-59 


99 


100 


86 


68 


14 


28 


60-79 


89 


100 


94 


80 


6 


18 


80-100 


45 


100 


98 


89 


2 


9 


Total 


338 












Source: Unpublishe 


d data from Dr. John C. Ball, Addiction Research Center, 


National Institute on 


Drug Abuse. 


See also Ball and 



colleagues (1988). 



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THE EFFECTIVENESS OF TREATMENT 



Using more realistic effectiveness data— but from 
only low-dose programs— McGlothlin and Anglin 
(1981) compared clients who left methadone 
maintenance when a community clinic was closed 
in Bakersfield, California, with clients in another 
community's program, which remained open. For 
men, the ratio of crime-related economic benefits 
to treatment costs was 1.7 to 1, over a short, two- 
year period. Additionally, the continuous 
treatment group reported significantly higher rates 
of employment than those who had been closed out 
of treatment, although this factor was not formally 
valued in the study. The results for women were 
contrary but can be considered little more than a 
preliminary indication because the sample size was 
too small for statistical stability. A study of a 
public clinic methadone program closure in San 
Diego (Anglin et al., 1989a) showed virtually no 
net economic loss but also no net gain. In this 
instance, a private methadone program picked up 
a large proportion of the clients on a self-pay 
basis. 

The most comprehensive examination of economic 
benefits and costs of drug treatment was performed 
with data from the TOPS (Harwood et al., 1988). 
The data included the average cost of a treatment 
day in methadone programs in 1979, detailed 
interview measures of rates of criminal activities in 
the TOPS sample in the year before treatment, the 
period in treatment, and the year after discharge 
(where applicable). The study also factored in 
estimates of the average cost to society of 
particular crimes, based on surveys conducted in 
1979 by the Bureau of Justice Statistics. The 
benefits of methadone maintenance treatment in 
terms of reduced crime-related costs to law-abiding 
citizens (including the value of stolen goods) were 
$ 1 3 per day compared with the $6 per day average 
cost of the program. Moreover, multivariate 
regression analysis found significant benefits in the 
year following discharge, such that retention for an 
additional day in treatment was worth $11 per day 
in delayed benefits. The final benefit/cost ratio 
was therefore 4 to 1 . An alternative and much 
more conservative cost/benefit model in which 
only increases in employment (which were limited) 
rather than reductions in goods stolen (which were 



much larger) were valued found a cost/benefit ratio 
of about 1 to 1 . Using either model, methadone 
maintenance pays for itself on the day it is 
delivered, and posttreatment effects are an 
economic bonus. 



Conclusions 

Methadone maintenance is a treatment that is 
designed for severe dependence on heroin. Prior 
to admission to a methadone program, the great 
majority of clients are consuming large amounts of 
heroin and other illicit drugs and committing 
predatory crimes (including drug selling) on a 
daily basis, a behavior pattern usually extending 
back several years or more. Although methadone 
is a relatively long-acting narcotic analgesic and 
produces dependence symptoms, the consumption 
of a clinically adjusted oral dose yields a steady 
metabolic level of the drug, produces little if any 
behavioral or subjective intoxication, and does not 
impair functioning or generate appreciably morbid 
side effects. Once such a solid, comfortable level 
is reached, suppressing the psychophysiological 
cues that precipitate and reinforce opiate craving, 
the client is amenable to counseling and related 
services that can help shift his or her orientation 
and lifestyle away from drug seeking and related 
crime and toward more socially acceptable 
behaviors. 

Methadone maintenance has been the most 
rigorously studied of all the drug treatment 
modalities, and the studies have yielded positive 
results (although some programs have good and 
others poor client compliance with rules against 
illicit drug use and criminal activity). 
Nevertheless, methadone maintenance is a 
controversial treatment: its critics contend that 
methadone clients have "merely" switched their 
dependence to a legally prescribed narcotic and 
that many clients continue to use heroin and other 
drugs intermittently and to commit crimes, 
including the sale of their take-home methadone. 
In the committee's judgment, these controversies 
and reservations are neither trivial nor in 
themselves compelling. The issues are to what 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



extent undesirable behaviors are reduced and 
positive behaviors increased as a result of 
methadone maintenance (in comparison with no 
treatment or with alternative treatment measures) 
and whether poorly performing programs can be 
improved. The extensive evaluation literature on 
methadone maintenance yields the following 
conclusions: 

■ There is strong evidence from clinical trials 
and similar study designs that heroin- 
dependent individuals have better outcomes 
on average (in terms of illicit drug 
consumption and other criminal behavior) 
when they are maintained on methadone than 
when they are not treated at all or are simply 
detoxified and released, or when methadone 
is tapered down and terminated as a result of 
unilateral client request, expulsion from 
treatment, or program closure. 

■ Methadone dosages need to be clinically 
monitored and individually optimized, but in 
general most clients have substantially better 
responses when maintained at the higher 
rather than lower end of the dose ranges 
currently being prescribed (up to 100 mg/day). 

■ During and after methadone maintenance 
treatment, criminal behavior declines and 
employment increases relative to untreated 
comparison groups, and the utility of these 
results substantially exceeds the cost of the 
treatment, especially when both the crime 
and employment dimensions are considered 
over an extended time period. 

Methadone maintenance is not the answer for 
every heroin-dependent individual. At any one 
time, perhaps one-eighth to one-fifth of all 
individuals who were recently dependent on heroin 
can be found in a methadone maintenance 
program." This figure could undoubtedly be 

"This estimate derives from experiments such as that of Bale 
and colleagues (1980), which is described in the following 
section, and from national surveys of the treatment system, 
described in Chapter 6, combined with estimates of the 
prevalence of heroin dependence. 



increased if program quality were optimized, 
hostile stereotypes of methadone treatment 
eliminated, and availability extended. When 
viewed in terms of lifetime prevalence, the number 
of current heroin-dependent individuals who will at 
some time enter the portals of methadone is 
higher, probably 30 to 40 percent. This range, 
like the preceding figure, is necessarily only an 
approximation because the research data that could 
give more precision to these estimates are 
inadequate, particularly in light of such recent 
developments as the AIDS epidemic. 
Nevertheless, in the committee's judgment, an 
improved network of methadone maintenance 
clinics might realistically be capable of reaching 
and dramatically accelerating the recovery of one- 
third of all those who become dependent on 
heroin. 



THERAPEUTIC COMMUNITIES 



What Is a Therapeutic Community? 

The residential therapeutic community, or TC, is 
a way of defining the nature of individual drug 
problems as much as a therapeutic approach to the 
rehabilitation or, more frequently, the habilitation 
of drug-dependent persons. It is from this 
understanding that the TC derives its encompassing 
and intensive approach. 

TCs were originally developed to treat the same 
problem as methadone maintenance programs: the 
"hard-core" heroin-dependent criminal. The 
residential TC has a broader perspective, however; 
it treats individuals who are severely dependent on 
any illicitly obtained drug or combination of drugs 
and whose social adjustment to conventional family 
and occupational responsibilities is severely 
compromised as a result of drug seeking— but who 
were compromised before drug seeking entered the 
picture. In this context, the specific drug (or more 
accurately, combination of drugs) represents a 
sociological fact more than a pharmacological 
foundation for treatment. In the 1980s, cocaine 
dependence has overtaken heroin dependence in 



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THE EFFECTIVENESS OF TREATMENT 



the TC population. The profile of TC clients is 
also more demographically diverse than that of the 
heroin-dependent population. Generally, on 
average, TC clients in the early 1970s, when there 
was a national counting system, were several 
years younger and predominantly white by a 
modest margin, a pattern that has continued in 
later, more partial statistics (e.g., the 1979-1981 
Treatment Outcome Prospective Study sample; 
Hubbard et al., 1989). I2 

The TC's group-centered methods encompass the 
following, all of which are grounded in an 
interdependent social environment with a direct 
link to a specific historical foundation: 

■ firm behavioral norms across a wide range 
of proscriptions and specifications; 

■ reality-oriented group and individual 
psychotherapy, which extends to lengthy 
encounter sessions focusing on current living 
issues or more deep-seated emotional 
problems; 

■ a system of clearly specified rewards and 
punishments within a communal economy of 
housework and other roles; 

■ a series of hierarchical responsibilities, 
privileges, and esteem achieved by working 
up a "ladder" of tasks from admission to 
graduation; and 

■ some degree of potential mobility from client 
to staff statuses. 

Because the therapeutic regimen of TCs has not 
been uniformly codified— and even if it had, would 
necessarily still involve substantial clinical 
discretion and creativity— there are great 
differences across programs in their recommended 
lengths of stay, staff-to-client ratios, and types of 
staff. These differences, which may be determined 



12 TC clients were 57 percent white, 34 percent black, and 9 
percent Hispanic. Methadone clients were 16 percent white, 
58 percent black, and 26 percent Hispanic (Sells, 1974a). 



more by financial realities than by therapeutic 
philosophies, may have a great deal of influence 
over the differential clinical effectiveness of TCs. 



De Leon (1986:5,7-8) has 
approach as follows: 



summarized the 



The TC views drug abuse as a deviant behavior, 
reflecting impeded personality development and/or 
chronic deficits in social, educational and economic 
skills. Its antecedents lie in socio-economic 
disadvantage, poor family effectiveness and in 
psychological factors. . . affecting some or all areas of 
functioning. . . . Thinking may be unrealistic or 
disorganized; values are confused, nonexistent or 
antisocial. 

Physiological dependency is secondary to the wide 
range of influences which control the individual's drug 
use behavior. Invariably, problems and situations 
associated with discomfort become regular signals for 
resorting to drug use. 

Thus, the problem is the person, not the drug. . . . In 
the TC's view of recovery, the aim of rehabilitation is 
global. . . . The primary psychological goal is to 
change the negative patterns of behavior, thinking, and 
feeling that predispose drug use; the main social goal 
is to develop a responsible drug free lifestyle. Stable 
recovery, however, depends upon a successful 
integration of these social and psychological goals. 

Sugarman (1986:66,69) elaborates further: 

All models of the TC involve a set of explicit behavior 
norms which members support and a set of contingent 
sanctions, positive and negative. . .hierarchical 
programs have extensive and demanding limits, strictly 
enforced, on the grounds that addicts need to learn self- 
control, and to experience the security of a firm 
framework of order. . . . Behavioral limits and 
sanctions plus positive peer pressure engender a short- 
term process of behavior modification. Even though 
this changed behavior is dependent upon the external 
controls of the social setting, still it has a real 
significance. . . . The message is: you can change in 
ways that you would not have thought possible. 

The self-sufficient group is a particularly important 
setting for learning the nature of social responsibility 
and the interdependence of individual interests. 
Ideally, the ordinary family and the ordinary peer 
groups that a child experiences in growing up convey 
this kind of learning; in practice, the lesson is often 
missed. . . . 



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To a significant extent the TC simulates and 
enforces a model family environment that the 
client, so to speak, should have had during 
critically formative preadolescent and adolescent 
years. The TC tries to make up for lost years of 
formation in an intensive, relatively short period of 
time— approximately 6 to 12 months of residential 
envelopment and an additional 6 to 12 months of 
gradual reentry to the outside community prior to 
"graduation." There is encouragement as well of 
continued alumni involvement for the benefit of 
role modeling for new residents, recognition and 
reinforcement for the graduate, and psychological 
and financial support for the program. 



How Well Do Therapeutic 
Communities Work? 



Conclusions about the effectiveness of TCs are 
limited by the difficulties of applying standard 
clinical trial methodologies to a complex, dynamic 
treatment milieu and a population resistant to 
following instructions. Randomized trials or 
natural experiments in the community, which 
would permit a well-controlled comparison of 
clients admitted to TC treatment versus an 
equivalent group (e.g., persons seeking treatment 
but denied admission, individuals admitted to other 
treatment modalities or arbitrarily excluded from 
TC treatment as a result of program closure) are 
not feasible or appropriate; when attempted, such 
experimental protocols have failed (see Bale et al., 
1980). Currently, the strongest conclusions on the 
effectiveness of TCs are based on nonrandomized 
or nonexperimental but rigorously conducted 
studies of clients seeking admission to therapeutic 
communities. It is therefore worthwhile to look 
more closely at the nature, strengths, and 
weaknesses of such evidence. 



The Character of Nonexperimental 
Evaluations 

In nonrandomized or nonexperimental studies of 
treatment effects, conclusions generally depend on 



two kinds of comparisons. One is the contrast of 
observed TC outcomes with the record of similarly 
troubled individuals from the pretreatment era 
(e.g., those seen at Lexington or other prisons or 
hospitals). The problem with such comparisons is 
that one cannot be certain that the people of one 
historical period are totally similar to those of 
another. Likewise, there may or may not be 
similarities between a group seeking TC (or any 
other specific) treatment and a group seeking 
detoxification, or between a self-selected group 
from the community and a group culled from the 
drug-dependent population by the criminal justice 
system. Those seeking admission to TCs might 
(although they just as easily might not) represent 
a different kind of drug population or a very 
specialized slice of the population, or at least a 
different enough slice to honestly confound any 
comparisons of this sort. Because the same data 
are not collected on the different groups being 
compared, one cannot really reduce this 
uncertainty very much. 

The second comparisons are internal ones, between 
those who enter TC treatment and those who apply 
for it but break off the process before entry, and 
between clients staying for longer versus shorter 
periods of treatment (receiving, in effect, larger 
and smaller "doses" of TC). In this case, the 
groups at least are being compared within the same 
time and data collection frame. Still, there may be 
selection effects that threaten the validity of the 
comparison, that is, its capacity to determine 
treatment effects. Those who stayed may have 
been different to begin with from those who left 
earlier. For example, they may have been 
intrinsically more or less likely to do well, 
treatment or no treatment (because of lesser or 
greater initial criminality, shorter or longer drug 
histories, better or worse family support). These 
differences may bias the comparison one way or 
another— either in favor of or against treatment 
effectiveness. 

To guard against such biases, researchers rely on 
baseline measurements and statistical adjustments 
to control for preadmission client characteristics 
that might account for differential retention or 



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THE EFFECTIVENESS OF TREATMENT 



outcome. 13 These procedures increase one's 
assurance that the results are not confounded by 
selection effects; however, because some 
pretreatment characteristics that might conceivably 
affect retention and outcome may not have been 
measured well or even measured at all, they do not 
offer as much assurance as a successfully 
implemented, randomized clinical trial with 
minimal attrition. 

The lack of randomized trials involving TCs is in 
some ways not surprising; most medical and 
criminal procedures became widely used without 
the benefit of such trials. The early success stories 
from the therapeutic communities Synanon and 
Daytop Village, in contrast to most treatment 
modalities' gloomy prior experience with heroin 
addiction, were positive and convincing enough 
that many clinicians and policymakers backed the 
establishment of TCs in the late 1960s and early 
1970s. The scientific community paid them 
relatively little attention (a notable exception was 
Yablonsky, 1965), and many researchers viewed 
randomized trials as impossible to perform because 
heroin cases are so prone to noncompliance. 14 

13 The causal model here attributes the client's status at a later 
point in time to three kinds of factors: predisposing conditions, 
which are controlled for by the baseline measurement 
procedures (e.g., why the client sought treatment, how much 
recovery the client wants to achieve); exterior factors during 
treatment, which are assumed to affect clients more or less at 
random; that is, they are not correlated with being admitted to 
treatment (changes in the price of drugs, for example, or police 
attitudes toward an individual, or the likelihood of being caught 
in a job layoff); and the units of treatment received, the 
element whose effects the researcher really wants to measure. 
There are three corresponding sources of error: unmeasured 
predisposing conditions, exterior factors that are correlated 
with being in treatment, and variations in the consistency of 
treatment units. 

14 The problem of heroin-dependent individuals' noncompliance 
with experimental and control protocols is not specific to 
experiments involving TCs. Noncompliance has compromised 
attempts to compare alternative pharmacologically based 
modalities, as vividly demonstrated in several large-scale 
studies, including the attempted comparison of the 
effectiveness of methadone maintenance versus maintenance 
with the narcotic antagonist naltrexone (National Research 
Council, 1978) or methadone versus the longer acting 
methadone congener LAAM (Savage et al., 1976; Ling et al., 
1978). 



The Bale Study 

The one notable attempt to undertake an 
experimental evaluation of the effectiveness of TCs 
compared with groups who were not treated or 
who were treated in other ways was conducted in 
California by Bale and coworkers (1980). This 
study, which examined methadone maintenance as 
well as TCs, did not work well as a random- 
assignment trial; in addition, the subject population 
is skewed from national norms. Nevertheless, its 
results are unique, important, and deserving of 
detailed attention for they underwrite much of the 
confidence that can be attached to results from 
studies that had no untreated control groups. 

The subjects were 585 heroin-addicted male 
veterans who sought and gained entry to the 
Veterans Administration (VA) Medical Center in 
Palo Alto, California, for a 5-day opiate 
detoxification program during an 18-month intake 
period in the mid- 1970s-- who also met the study's 
requirements. 15 When asked, about one-fifth of 
the subjects denied any interest in transferring to 
a VA drug treatment program after detoxification 
(some later changed their minds). The balance 
(plus the changers) were randomly assigned to 
either of two methadone maintenance clinics or 
one of three residential programs, each a different 
kind of 6-month TC. 

The clinical staff invested significant time in trying 
to enlist every subject in his assigned program, 
and the overall rate of transfers from detox to VA 
programs doubled as a result. Nevertheless, the 
random-assignment design was thoroughly 

1 'There were 710 total drug detox admissions; exclusions from 
the study sample were for pending felony charges (51 ), major 
psychiatric problems (41), falsified eligibility for VA treatment 
(13), and miscellaneous reasons (19). The study population 
differed from the opiate-dependent DARP sample in several 
important particulars: they were all honorably discharged 
veterans (100 percent versus 25 percent in the DARP), all male 
(100 percent versus 77 percent), and mostly high school 
graduates (71 percent versus 39 percent) and ex-convicts (80 
percent versus 60 percent) who used other drugs in addition to 
heroin (72 percent versus 52 percent). They were also less 
often black (41 percent versus 54 percent) or Hispanic (13 
percent versus 22 percent) and more often employed (76 
percent versus 57 percent) in white-collar jobs (36 percent 
versus 1 1 percent). 



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SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1. CHAPTER 5 



TABLE 5.2A 


Subject Compliance 


(percentage) with Assignment to a Therapeutic 


Program 






















Program Assigned 




















Detox 
















(self- 




Program Entered 


TC I" 


TC II 




TC III 


Methadone 


selected) 


Total 




(79) b 


(147) 




(137) 


(94) 


(128) 


(585) 


None 


44 


40 




36 


28 


59 


42 


Non-VA 


9 


16 




20 


20 


28 


19 


TCI 


18 c 


1 




2 


5 





4 


TC II 


13 


24° 




9 


9 


6 


13 


TC III 


13 


10 




22 c 


8 


2 


11 


Methadone 


4 


10 




12 


31 c 


4 


12 


Total" 


100 


100 




100 


100 


100 


100 



"TC = therapeutic community. 

"Numbers in parentheses are subjects assigned to the program. 

Percentage entering program to which assigned. 

d Totals may not add to 100% due to rounding. 

Source: Bale et al. (1980). 



720 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



THE EFFECTIVENESS OF TREATMENT 



TABLE 5.2B Subject Compliance (number and percentage) with Assignment, 
Combining Therapeutic Communities (TCs) 











Progi 


*am Assigned 












Methadone 


Detox 














(eligib 


ility 


(self- 










TCs 




(requii 


r ement) 


selected) 


Total 




Program Entered 


No. 


% 


No. 


% 


No. 


% 


No. 


% 


None 


143 


39 


26 


28 


76 


59 


245 


42 


Non-VA 


58 


16 


19 


20 


36 


2 


113 


19 


TC 


129" 


36" 


20 


22 


11 


8 


160 


28 


Methadone 


33 


9 


29 s 


31' 


5 


4 


67 


12 


Total" 


363 


100 


94 


100 


128 


100 


585 


100 



"Number or percentage entering program to which assigned. 
"Totals may not add to 100% due to rounding. 

Source: Bale et al. (1980). 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



121 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



compromised (Tables 5-2a and 5-2b). Less than 
half of the randomly assigned subjects entered and 
spent as long as a week in any of the VA treatment 
programs, and only half of those entered the 
specific programs they had been assigned to (the 
others waited out at least a 30-day exclusion period 
to enter their own preferred program) . Altogether, 
42 percent of the total study cohort did not enter 
any kind of treatment during the follow-up year, 
about 28 percent entered one of the VA TCs, 12 
percent entered a VA methadone clinic, and 19 
percent entered a non-VA program. 

The lack of compliance affected the study so 
profoundly that research analysts (who were 
independent of the clinical staff) were obliged to 
switch from the simplicity of randomizing 
assumptions to the use of multivariate statistical 
procedures to control for initial differences in age, 
ethnicity, prior treatment, drug use patterns, and 
criminal history among treatment and nontreatment 
groups. 

At the one-year follow-up, those who had been 
successfully recontacted (the follow-up contact rate 
was 93 percent) were divided among the no- 
treatment (41 percent), non-VA (21 percent), 
short-term TC (14 percent), long-term TC (14 
percent), and methadone (11 percent) options. 16 
Controlling for pretreatment characteristics, the 
no-treatment, non-VA treatment, and short-term 
TC groups were statistically indistinguishable from 
each other at the follow-up. Compared with these 
groups, however, the long-term TC and methadone 
client groups (comprising one-fourth of the total 



"Retention in treatment was not high for the 6-month 
residential programs. About 13 percent of the clients stayed 
less than 1 week (these were considered "no treatment"), 57 
percent dropped out within 7 weeks, and 85 percent left 
treatment before 6 months. In contrast, about 65 percent of 
clients entering methadone maintenance were continuously in 
treatment for the follow-up year. 

The TC group was therefore divided at the median length of 
stay (for all admissions who had remained longer than a week), 
which was 50 days. The short-term group stayed in treatment 
about 3 weeks on average; the long-term group stayed about 
20 weeks on average. The methadone group on average 
stayed in treatment about 40 weeks. 



program) were clearly different. The long-term 
TC and methadone clients were: 

■ two -thirds as likely to have used 
heroin in the past month (41 
percent versus 64 percent); 

■ three-fifths as likely to have been 
convicted during the year (22 
percent versus 37 percent); 

■ one-third as likely to be 
incarcerated at year's end (7 
percent versus 19 percent); and 

■ one-and-a-half times as likely to 
be at work or in school at year's 
end (59 percent versus 40 
percent). 

The long-term TC group ranked somewhat better 
than the total methadone group on each measure, 
but the differences were not large enough to be 
statistically distinguishable in a sample of this size. 

Other Significant Follow-up Studies 

Beyond the efforts of Bale and colleagues, there is 
a significant controlled observational literature on 
therapeutic communities. The bulk of these 
studies have focused on clients admitted to 
particular programs such as Phoenix House and 
Daytop Village in New York; in addition, the 
DARP (Simpson et al., 1979) and the TOPS 
(Hubbard et al., 1989) separately examined clients 
who were admitted to about 10 TCs across the 
country (not the same programs and 10 years 
apart) . 

The most extensive outcome evaluations from a 
single program come from Phoenix House in New 
York. DeLeon and coworkers (1982) studied a 
sample of 230 graduates and dropouts and found 
that before admission the two groups were very 
similar with respect to criminal activity and drug 
use but that dropouts had somewhat greater 
employment. After treatment, the status of both 



122 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



THE EFFECTIVENESS OF TREATMENT 



groups was much better than before, but graduates 
had dramatically superior posttreatment outcomes 
compared with dropouts (Table 5-3). 17 

The Drug Abuse Reporting Program (DARP) 
provided further important controlled observational 
findings about the effectiveness of therapeutic 
communities (Sells, 1974a,b). The mean and 
median lengths of stay in the traditional TCs 
involved in the DARP were close to 7 months, 
which was well below the average 16-month 
treatment plan. At 12 months after admission, 71 
percent of those admitted had left the TC 
voluntarily or by expulsion, although only 5 
percent had completed their treatment plan by 
then; the ultimate graduation rate was 23 percent 
(Simpson et al., 1979). 

Most of the DARP's outcome measures at one 
year after discharge (daily opiates, daily 
nonopiates, arrests, incarceration) were 
significantly better for TC clients compared 



17 One smaller study that is notable for its careful execution 
followed a random sample of graduates and dropouts from a 
Connecticut TC (Romond et al., 1975) with an 18- to 24- 
month treatment plan. The authors found few pretreatment 
differences between the graduate and dropout groups except 
that women were much less likely than men to graduate. All 
20 graduates in the sample were successfully contacted; 1 of 
31 dropouts in the sample were not located, and 1 refused an 
interview, yielding 20 successful contacts. Graduates had 
spent on average 21 months in treatment, compared with 5.7 
months for dropouts (range: 1 days to 1 6 months). Interview 
data were corroborated through formal and informal community 
networks. 

Graduates had consistently better outcomes. Only 1 of 20 
graduates relapsed to dependence for some part of the follow- 
up period, another 5 sometimes used nonopiate drugs, and 14 
remained drug free throughout the interval; altogether, 
graduates spent 0.5 percent of the follow-up period dependent. 
Of the 20 dropouts interviewed, 1 4 relapsed to dependence for 
some of the follow-up period, 2 more used nonopiates 
occasionally, 1 was incarcerated for the entire period, and 3 
had used no drugs; 35 percent of the dropouts' posttreatment 
time was spent as drug dependent. Ninety-four percent of the 
graduates' posttreatment time had been in school or employed, 
and at the time of the interview, none were institutionalized 
and 2 had some criminal justice involvement (probation, parole, 
pending case). Forty percent of the dropouts' posttreatment 
time had been in school or employed; at the time of the 
interview, 4 were in other drug programs, 1 was in a 
psychiatric hospital, 4 were in jail, and 7 others had a pending 
court case or were on probation or parole. 



with the outcomes of detoxification-only and 
intake-only cases (Simpson et al., 1979). As in 
the Bale study, the multivariate-adjusted outcomes 
for TCs and methadone maintenance clients 
(matched for time since admission) on daily opiate 
use, nonopiate use, employment, and a composite 
index were quite similar. The length of stay in 
treatment was a positive, robust, significant 
predictor of posttreatment outcomes (drugs, jobs, 
and crime). Among clients staying more than 90 
days in treatment, there was a positive and linear 
relationship between outcome and retention. The 
outcomes among clients staying less than 90 days 
were indistinguishable from detox-only and intake- 
only cases, and there was no discernible relation 
between outcome and short lengths of stay. 

The final results of the TOPS, which were derived 
using multivariate logistical regression to control 
for pretreatment demographics, drug use, and 
criminality, yielded the familiar positive 
relationship between length of stay and outcome 
but with no clear threshold (Hubbard et al., 1989; 
see Figure 5-3). One year or more in a TC was 
significantly related to reduced heroin use, lower 
crime involvement, and increased employment at 
a 12-month follow-up. The odds of having 
problems with heroin or crime were about two- 
fifths as great for the long-term residential clients 
as for early dropouts, and their odds of having a 
job were nearly 1.7 times higher. Cocaine use 
followed a similar pattern, but the effect was not 
statistically significant. Alcohol problems were 
not related to treatment retention. 

In summary, multisite evaluations of the DARP 
(Simpson et al., 1979; Simpson, 1981) and the 
TOPS (Hubbard et al., 1989) both produced strong 
results supporting those of Bale and coworkers and 
the one or two useful single-program studies. 
Even in the absence of clinical trials, it is difficult 
to credit any explanation of these results other than 
the following: TCs can strongly affect the 
behavior of many of the drug-dependent 
individuals who enter them, and retention in 
treatment after some minimum number of months- 
how many seems to vary with the program— is 
positively and significantly related to improved 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



123 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1. CHAPTER 5 



TABLE 5.3 Follow-up Results of Treatment at Phoenix House (New York City) 
Measured on Crime, Drug Use, and Employment Indices (percentage) 









Post- 






N 


Pretreatment 


treatment 


P 


CRIME 










Total 


226 


96.5 


29.2 


<.001 


Dropouts 


154 


97.4 


40.9 


<.01 


Graduates 


72 


94.4 


4.2 


<.001 



Dropout/graduate differences, p Not signif. <.001 



DRUG USE 








Total 229 


94.3 


32.3 


<.001 


Dropouts 156 


96.8 


43.6 


<.05 


Graduates 73 


89.0 


9.2 


<.001 


Dropout/graduate differences, p 


Not signif. 


<.001 





EMPLOYMENT' 










Total 


230 


32.6 


75.7 


<.001 


Dropouts 


156 


36.5 


66.0 


<.001 


Graduates 


74 


24.3 


95.9 


<.001 



Dropout/graduate differences, p <.10 <.001 



"Employed more than 50 percent of the time. 

Source: De Leon et al. (1982:Table 5). 



124 NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



THE EFFECTIVENESS OF TREATMENT 



r- 
< 




Heroin 



Cocaine 



Alcohol 
OUTCOMES 



Crime 



Work 



FIGURE 5-3 Outcomes and retention in therapeutic communities based on data from the Treatment 
Outcome Prospective Study and shown as odds ratios derived from multivariate analyses. The odds 
that members of the intake-only group will report a successful outcome at follow-up are compared with 
the odds for those who were in treatment for 1-13 weeks. 14-26 weeks, 27-52 weeks, and 53 or 
more weeks. The intake-only odds are standardized or set equal to 1 for each criterion; the other 
group odds are expressed as ratios of 1 . 

Source: Hubbard at al. (1989). 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



12S 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



outcomes as measured by illicit drug consumption, 
other criminal activity, and economically 
productive behavior. 

Why Do the Results of 
Therapeutic Communities Vary? 

No one really knows why there is such variation in 
TC performance and client responses (although 
strong views are often expressed about the matter) 
because there has been virtually no systematic 
research about the determinants of client success 
and failure in TCs. It is highly plausible that the 
results of TC treatment depend on its primary 
elements: the client's motivations, the quality and 
quantity of staffing, and the psychosocial 
organization and therapeutic design of the 
program. The committee heard anecdotally that 
TC staffing has been problematic during the 1980s 
as a result of constant budget pressures (staff 
numbers or salaries can be cut or held down more 
readily than room-and-board expenses) and rising 
competition with private-tier outpatient and 
chemical dependency treatment providers for 
credentialed, experienced staff. Yet there are no 
studies that specifically investigate how TC staffing 
relates to the effectiveness of treatment. 

There are clearly wide variations in outcome 
indicators across programs. Client-Oriented Data 
Acquisition Process (CODAP) reports published 
from 1976 through 1981 make it possible to 
examine variations across cities in client status at 
discharge. The crude city differences are not 
adjusted to account for differences in the 
characteristics of clients treated in the various 
cities, nor can they be broken down to the 
program level. Nevertheless, the 1976-1981 
CODAP reports demonstrate graphically that 
effectiveness varied significantly from area to area 
and undoubtedly even more so from program to 
program. 

The year 1980 was one of relative program 
stability: the treatment system had been in place 
from five to six years and had not yet been 
disrupted by the massive system changes that 
resulted from the institution of block grants with 



their devolution of management responsibility to 
the states. Yet very large variations were seen in 
the treatment "completion" rates reported for that 
year by residential programs (Figure 5-4), most of 
which were TCs. From the figure it is apparent 
that TCs in some cities diverged widely from the 
national average. Although the average residential 
completion rate across the nation was 10 percent, 
a sizable number of communities had averages 
well below and above this rate: 23 cities had rates 
between 5 and 15 percent, 9 cities were below 5 
percent, 13 were between 15 and 24 percent, and 
9 were above 25 percent. These variations have 
not been analyzed for possible attribution to 
differences in client characteristics, treatment 
process, quality of staff, or random processes. 
There is also currently no usable evidence of 
national scope showing whether client discharge 
statuses still exhibit such differences across 
geographic areas, or why. 



Costs and Benefits of 
Therapeutic Community Treatment 

Most evaluations of TCs indicate that they are 
cost-effective or cost-beneficial, or both. There 
have been fewer rigorous evaluations of costs and 
benefits than of cost-effectiveness, however. A 
simulation by Maidlow and Berman (1972) showed 
that a TC produces $213,000 of economic benefits 
to society per client at a cost of $14,700 (a 
benefit/cost ratio of 14.5 to 1). These authors 
concluded that TCs were highly cost-beneficial 
compared with prisons (which were much more 
expensive and had high recidivism rates). Rufener 
and coworkers (1977) focused only on benefits 
after treatment (ignoring benefits during treatment) 
and tried to sort out the benefits that accrue 
variously to the client, the government account, 
and society as a whole. They estimated that the 
combined benefit/cost ratio of TCs after the 
treatment period was 1.9 to 1. As discussed 
earlier, however, both of these sets of cost/benefit 
ratios are biased upward because the assumptions 
used to produce them were overly optimistic 
compared with what is now known about treatment 
retention and effectiveness. 



126 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



THE EFFECTIVENESS OF TREATMENT 





24 




22 




20 


<f) 


18 


LU 




H 


16 


O 


14 


u_ 




O 


12 


DC 




LU 


10 


CQ 




S 


8 


Z3 




Z 


6 




4 




2 











iww 





f? N U ^ ,^ ^ <b^ <^ 

# N* # ♦' £ * 

PERCENTAGE OF DISCHARGES 
COMPLETING TREATMENT 



FIGURE 5-4 Variations in "completion" rates of opiate clients in residential programs in U.S. cities, 
1980. 

Source: National Institute on Drug Abuse (1981). 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



127 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1, CHAPTER S 



2.2 
2 

1.8 

1.6 

1.4 

g 1.2 

< 

DC 



1 

0.8 

0.6 

0.4 
0.2 r 




i ; . ! . ; . : .!.;.i.jAv.-.| 

Kg&;&;:$:l Intake only 

1-13 weeks 



| 14-26 weeks 












s 






'■•'■•'■ v 






si 

y.' o 



^ 



<>1 



SI 



Heroin Cocaine Alcohol 

OUTCOMES 



Crime 



Work 



FIGURE 5-5 Outcomes and retention in outpatient nonmethadone programs based on data from the 
Treatment Outcome Prospective Study and shown as odds ratios derived from multivariate analyses. 
The odds that members of the intake-only group will report a successful outcome at follow-up are 
compared with the odds for those who were in treatment for 1- 13 weeks, 14-26 weeks, and more 
than 26 weeks. The intake-only odds are standardized or set equal to 1 for each criterion; the other 
group odds are expressed as ratios of 1. 

Source: Hubbard at ml. (1989). 



128 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



THE EFFECTIVENESS OF TREA TMENT 



A more realistic cost-effectiveness study using the 
DARP data base (Rufener et al., 1977a) found that 
TCs generally produced greater differentials than 
methadone or outpatient nonmethadone treatment 
in terms of legitimate income and employment 
status after treatment versus before. But 
methadone was decidedly more cost-effective- 
measured as the cost per added day of desirable 
outcome—because it was cheaper. Of course, these 
comparisons work only to the degree that those 
entering one treatment would as readily have 
entered the other. 

A cost/benefit study of the Gaudenzia House TC 
(Griffin, 1983) compared the expense of operations 
over a five-year period with the benefits from 
reduced criminal activity and increased social 
productivity. The analysis distinguished the 
benefits to be derived from treatment "successes" 
and "failures," finding positive ratios of benefits to 
costs for both groups (9 to 1 for "successes" and 
3.4 to 1 for "failures"). Benefits accrued even for 
"failures" because while in residence for treatment 
they were unable to commit as many street crimes 
(analogous to the incapacitation effect of 
incarceration) as they would have if not in 
residence. 

Most recently, Harwood and colleagues (1988) 
analyzed the TOPS data base, examining the 
reduced crime-related impacts on society that 
result from drug treatment. A particularly 
important finding was that TC treatment, as with 
methadone treatment (see the section above entitled 
"Costs and Benefits of Methadone Treatment"), 
virtually pays for itself during the time it is 
delivered, owing to the reduced criminal activity 
of clients in treatment relative to either the pre- or 
posttreatment periods. Further benefits accrue 
after leaving treatment. The final benefit/cost ratio 
for TCs was 3.8 to 1 using the primary measure 
(the costs of crime) and 2.1 to 1 using a more 
conservative employment-oriented measure. 

Conclusions 

TCs are for the most part designed to treat 
individuals who are badly impaired by drug 



problems and other deficits, and client decisions 
about whether to seek TC treatment reflect an 
awareness of that design. Even those who do seek 
treatment often drop out of TCs in short order, in 
contrast to the much higher retention rates of those 
who enter methadone maintenance. There is, 
nevertheless, a sizable population who not only 
find TC treatment initially attractive but also will 
remain in this modality for a substantial fraction 
(up to the whole course) of planned treatment. 
This segment is distinct from the typical 
methadone maintenance population: it is 
appreciably younger, more heavily white, and 
more likely to use multiple drugs. 

The committee considers the evidence about the 
following to be fairly persuasive (although not 
ironclad): those clients who stay in TCs for at 
least a third or half of the planned course of 
treatment, a threshold that seems to vary greatly 
from program to program— that is, those who stay 
in treatment for at least 2 to 12 months, varying 
from program to program for reasons that are not 
yet clear— are much closer to achieving the 
treatment's goals at follow-up than those who drop 
out earlier. The outcomes of the earlier dropouts 
basically cannot be distinguished from those of 
individuals who did not enter any treatment 
modality. 

These improvements over nontreatment, which are 
estimated to be in the neighborhood of one- to 
two-thirds reductions in the rates of primary drug 
consumption and other criminal activity and half- 
again increases in the rates of employment or 
schooling, vary with the amount of time spent in 
treatment. TC graduates have outcomes that are 
even better than these rates, but they are a small 
percentage (usually 15 to 25 percent) of total TC 
admissions. What is most important here is that 
graduates are not the only ones who benefit 
themselves and society as a result of spending time 
in a TC. Even for those individuals who "split" 
early, even for those who show no later effects, 
the TC may be a good social investment 
considering that a day in a TC is a day away from 
street crime. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



129 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1. CHAPTER S 



Q 

UJ 

rr —J 
LU < 



< 

O 

z 
z 
o 



o 



in 

o 
i— 
o 
o 

X 

< 

z 

CD 



Oo5 
2 D 

ZUJ 

up 



100 r 



80 



60 



40 



20 



Preadmission 




Postadmission 




non-CAP 



CAP 

_J | 



2 4 6 
YEARS 



8 10 12 



FIGURE 5-6 Effects of California Civil Addict Program on daily narcotics use. The percentage of 
nonincarcerated time during which subjects reported using narcotics daily is shown for 8 pre- and 13 
postadmission years. The vertical line at A denotes admission to the California Civil Addict Program 
(CAP). The CAP group (N = 289) was committed to the program for 7 years; the non-CAP (N = 292) 
was discharged from the program by writ shortly after admission owing to procedural errors. Data for 
CAP for year 1 are missing because this group was incarcerated nearly the whole year in the CAP 
facility. 

Source: McGlothlin et al. (1977b). 



730 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



THE EFFECTIVENESS OF TREATMENT 



OUTPATIENT NONMETHADONE 
TREATMENT 



What Is Outpatient Nonmethadone Treatment? 

Outpatient nonmethadone (OPNM) programs range 
in duration from the one-time assessments and 
referrals of drop-in and "rap" centers to virtual 
outpatient therapeutic communities with daily 
psychotherapy and counseling intended to continue 
for a year or longer (Kleber and Slobetz, 1979). 
In between are the vast majority of programs, 
which see clients once or possibly twice weekly 
and deliver services based on theoretical 
approaches from psychiatry, counseling 
psychology, social work, therapeutic communities, 
or the 12-step Anonymous creed. Some programs 
contract extensively with Treatment Alternatives to 
Crime agencies or probation departments (see 
Chapter 4), monitoring the shared clients' 
compliance with probation conditions—particularly 
through administration of drug tests—and offering 
no other therapeutic services. 

Some OPNM programs utilize psychoactive 
medications prescribed by psychiatrists or other 
physicians on staff. These agents may be 
medications used initially in detoxification to 
ameliorate withdrawal symptoms, maintenance 
antagonists that prevent intoxication (e.g., 
naltrexone), medications to control drug cravings 
after withdrawal (especially innovative cocaine 
pharmacotherapies), or drugs that address 
psychiatric disorders (depression, mood disorders, 
schizophrenia, etc.). Programs with the requisite 
resources may deliver or link their clients to 
formal education, vocational training, health care 
(such as AIDS testing or treatment), housing 
assistance (especially for homeless clients), support 
for battered spouses and children, and other social 
services. 

The diversity of OPNM treatment defies easy 
summary and is matched by the heterogeneity of 
its client populations. These populations generally 
are not abusing opiates, usually are not involved in 



the criminal justice system (at least, were not so 
during the DARP and TOPS periods), and include 
significant proportions of abusing rather than 
dependent individuals— differing in all these 
respects from typical methadone and TC clients. 



How Well Does Outpatient 
Nonmethadone Treatment Work? 

The major conclusion that can be offered about the 
effectiveness of outpatient treatment is a familiar 
one: clients who remain in treatment longer have 
better outcomes at follow-up than shorter term 
clients. These conclusions are based entirely on 
multivariate results of the two major multisite 
evaluations, the DARP and the TOPS. In the 
Drug Abuse Reporting Program study of clients 
entering treatment from 1969 to 1972 (Sells, 
1974a,b; Simpson et al., 1979; Simpson, 1981), 
OPNM clients exhibited statistically significant 
follow-up improvements relative to pretreatment in 
terms of employment and consumption of opiates 
and nonopiates, but not in terms of arrest rates, 
which were much lower before treatment than they 
were in TC or methadone maintenance clients. 
The DARP comparison groups, those in detox 
programs and those who only made contact with 
treatment during intake, reported no significant 
pre- to posttreatment changes except in opiate 
consumption (Simpson et al., 1979). 

Analyses of retention (Simpson, 1981) produced 
results identical to those for TC clients: clients 
staying in treatment less than 90 days showed no 
improvement relative to the detox and intake-only 
clients, whereas those staying longer had improved 
outcomes on a composite score that incorporated 
drug, criminality, and productivity scales. For the 
90-days-plus group, outcome scores were strongly 
and significantly correlated with total length of 
stay. 

The larger and more recent Treatment Outcome 
Prospective Study (Hubbard et al., 1989) collected 
data on 1,600 OPNM clients admitted to 10 
programs. Clients again reported better 

performance during and after treatment than before 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



131 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



admission, and multivariate analyses strongly 
related posttreatment outcomes to length of stay, 
using multivariate logistical regression to adjust for 
client drug use histories and sociodemographic 
characteristics at admission (Figure 5-5). The 
analysis suggested that the critical retention 
threshold may be six months, but only 17 percent 
of TOPS outpatient clients were retained this long. 
OPNM dropout rates were quite high— significantly 
higher than for methadone or TCs. At four weeks 
the programs retained only 59 percent of clients; 
18 percent eventually completed the course of 
treatment. 



TOPS data base. Compared with a similar detox 
sample, increased treatment retention in OPNM 
programs had a modest but measurable impact on 
the amount of theft while in treatment, even 
though the OPNM treatment population was less 
criminally active than the populations in 
methadone treatment and TCs. An alternative 
measure, improvement in the amount of legitimate 
employment, produced a benefit/cost ratio of 4.3 
to 1, indicating that the benefits of OPNM are 
more pronounced in terms of the secondary goal of 
employment rather than as reductions in already 
low levels of criminal activity. Unlike the results 
of TC treatment, crime-related benefits of OPNM 
after discharge were not discernible. 



Why Do the Results of Outpatient 
Nonmethadone Treatment Vary? 



There is no answer to this question for OPNM 
programs. Although there is evidence of variation 
in program retention rates, there is very little 
information about what the "active ingredients" in 
this treatment modality are that might lead to these 
variations. One can only speculate that the same 
factors that emerge from methadone and TC 
research, in particular, staff quality and program 
design, may be equally important here. 



Benefits and Costs of 
Outpatient Nonmethadone Treatment 

Both of the major multisite studies, the DARP and 
the TOPS, have been analyzed with respect to the 
costs and benefits of OPNM treatment. Rufener 
and colleagues (1977a) compared the cost- 
effectiveness of the major treatment modalities for 
the DARP subsample of opiate clients. For this 
population, OPNM generally had poorer cost- 
effectiveness than methadone and TCs, but no 
attempt was made to address whether OPNM was 
more cost-effective than no treatment or whether 
longer treatment was more cost-effective than brief 
episodes. 

Harwood and coworkers (1988), using the methods 
described above for methadone and TCs, estimated 
a benefit/cost ratio of 1.3 to 1 for OPNM in the 



CHEMICAL DEPENDENCY TREATMENT 



What Is Chemical Dependency Treatment? 

Chemical dependency (CD) treatment (also called 
the Minnesota model, 28-day, 12-step, or 
Hazelden-type treatment) is the predominant 
therapeutic approach taken by the privately 
financed inpatient and residential programs 
identified in Chapter 6 as the "private tier" of 
providers. Virtually all of these programs were 
originally oriented toward alcohol problems but 
have increasingly served clients with illicit drug 
problems. The CD theory of the disorder and the 
modality's treatment approach have expanded from 
a focus on alcoholism that depended on the 
Alcoholics Anonymous principles (the 12 steps) to 
one more broadly addressing dependence on any 
chemical substance. Cook (1988a,b) has provided 
a concise historical review of the development of 
the Minnesota model. He notes the similarities 
between the underlying theories that shape CD and 
TC treatment but observes that they developed 
almost completely independently of each other. 

Almost exclusively, the goal of CD treatment is 
abstinence from alcohol and drugs. The client is 
viewed as a victim of a disease process but also as 
the person with the primary responsibility for 



132 



NIDA DRUG SERVICES RESEARCH SERIES, No. 2 



THE EFFECTIVENESS OF TREATMENT 



making behavioral changes that will promote 
abstinence, which will in turn eliminate problems 
resulting from alcohol or drugs. 

In its most sophisticated formulation, the CD 
approach views drug problems as having multiple 
causes. There is a physiological phenomenon at 
work, but psychological and sociocultural 
dimensions are of equal importance. The 
physiological component often requires some 
pharmacological intervention as an integral aspect 
of treatment. The treatment's psychological 
dimension highlights the impact of emotional, 
motivational, and learning problems on 
dependence. Sociocultural models explore the 
relation of drinking and drug problems to 
socialization processes and environments. CD 
treatment practices represent a blending of the 
Alcoholics Anonymous model of recovery, certain 
insights and prescriptions of somatic medicine, and 
psychiatric and behavioral science principles. 

Chemical dependency treatment is usually an 
intensive, highly structured three- to six-week 
inpatient regimen. Clients begin with an in-depth 
psychiatric and psychosocial evaluation and then 
follow a general education-oriented program track 
of daily lectures plus two to three meetings per 
week in small task-oriented groups. Group 
education teaches clients about the disease concept 
of dependence, focusing on the harmful medical 
and psychosocial effects of illicit drugs and 
excessive alcohol consumption. There is also an 
individual prescriptive track for each client, 
meetings about twice a week with a "focal 
counselor," and appointments with other 
professionals if medical, psychiatric, or family 
services are needed. Recently, there has been 
increasing emphasis on family (or "codependent") 
therapy and the concept that others may be acting 
as "enablers" of drug and alcohol consumption. 

Clients actively engage in developing and 
implementing a recovery plan, which is patterned 
on the "step work" (working through the 12 steps 
that lead to recovery) of Alcoholics Anonymous. 
Self-help is a large part of therapy; clients work 
with each other and are generally required to 



attend Alcoholics/Cocaine/Narcotics Anonymous 
(AA/CA/NA) meetings. 

Aftercare is considered quite important in CD 
treatment, but there are relatively few program 
resources devoted to it. It can last from three 
months to as long as two years and range in 
intensity from a simple monthly telephone follow- 
up to intensive weekly group therapy and 
individual counseling as needed. Clients are urged 
to continue an intensive schedule of AA/CA/NA 
attendance through the follow-up period, with 
continued contacts thereafter at a lower rate. 

CD treatment has some elements in common with 
the TC approach: abstinence as a goal, striving 
for behavioral changes to achieve abstinence, the 
client taking primary responsibility for his or her 
problems, and recovery in the context of mutual 
support, including that of counselors. But there 
are noteworthy differences between the two 
modalities. The inpatient or residential phase of 
the CD treatment plan is short relative to TC 
treatment, and the extended follow-up or aftercare 
phase is seldom if ever a strong and integrated 
program element. Because the hospital-based 
services of CD treatment do not require clients to 
perform housekeeping duties, there is more time 
for psychotherapy and educational work; in the TC 
process, however, housekeeping and other 
program maintenance responsibilities are 
considered an integral component of therapeutic 
learning. CD program staff, like TC staff, are a 
mixture of stable, recovering (from alcohol or 
drug dependence) individuals and professional 
clinicians from traditional health care, mental 
health, and social service disciplines. However, 
CD staff tend to be more heavily credentialed. 

CD treatment is full of educational work, including 
writing, reading, and lectures; there is little of the 
daily job routines or ladder of work responsibilities 
that are intrinsic to TC treatment and by which 
client progress is symbolized. (In CD programs, 
progress is made by ascending spiritual steps.) 
Most TCs depend heavily on advanced clients to 
direct the progress of new clients. Prior to 
admission, CD clients are usually enacting some 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



stable social roles, whereas TC clients almost 
always have massive functional and social deficits. 
CD programs, with their residential treatment 
duration, are more attractive to clients with greater 
initial functional and social resources: indeed, the 
prototypical CD client used to be fortyish, middle 
class, employed, white, and dependent on alcohol. 
Today, although the clientele is more diversified 
(programs are now seeing more clients with 
combined cocaine/alcohol problems, as well as a 
segment of adolescents with both psychiatric and 
drug diagnoses), these origins continue to shape 
the CD approach. 



How Well Does Chemical Dependency 
Treatment Work? 

Although CD programs have come to play a major 
role in the drug treatment world, the research data 
on this type of treatment for illicit drug problems 
are weaker than for the other modalities. There 
are no relevant experimental or quasi-experimental 
studies; there were no CD programs in the DARP 
or TOPS samples. Only one of the available 
observational studies of CD programs employs an 
untreated comparison group (Rawson et al., 
1986), 18 and none have collected data on 
admissions with short lengths of stay. There is 
also practically no use of multivariate statistics. 

The extent of reasonably certain knowledge about 
CD treatment is that clients who present drug 
problems at admission have poorer outcomes at the 
posttreatment follow-up than alcohol clients (with 
no illicit drug consumption) in the same programs. 
This finding is consistent across studies by the 
CareUnit system, the Chemical Abuse/ Addiction 
Treatment Outcome Registry (CATOR) follow-up 
service, and the Hazelden center in Minnesota. 



The CareUnit study (Comprehensive Care 
Corporation, 1988) sampled 1,002 adult clients 
who stayed at least five days in 1 of 50 different 
CareUnit programs in 1987. (CareUnits treated 
46,000 adults and adolescents in more than 200 
locations.) About 53 percent of the sample had 
used multiple substances before admission, and 29 
percent reported polydrug consumption on a daily 
basis. Clinical program staff interviewed 723 
clients from the sample at least one year after 
discharge. Sixty-one percent were classified as 
recovering at follow-up (fewer than four instances 
of use since discharge). Abstinence was poorer 
for preadmission consumers of illicit drugs (54 
percent for those who had used cocaine and 48 
percent for those using marijuana) and polydrugs 
(56 percent) than for consumers primarily of 
alcohol (63 percent). The strongest indicator of 
outcome was attendance at self-help groups after 
discharge: only 48 percent of nonattenders were 
recovering, compared with 79 percent of those 
attending the groups more than 29 times. 

The CATOR study is a multisite comparison of 
independent programs. Hoffmann and Harrison 
(1988) found that at least 38 percent of clients in 
22 adult inpatient programs in the Midwest had an 
admission history that included illicit drugs. 
However, the study excluded clients with fewer 
than 10 days in treatment, followed virtually no 
one who did not complete treatment, and reached 
only 37 percent of completers at the two-year 
follow-up interview. Few results were detailed 
specifically for individuals with drug problems, but 
the authors note that "[p]revious CATOR analyses 
have consistently found that polydrug users have 
the poorest prognosis for abstinence, followed by 
regular marijuana users. . . . The relationship of 
use pattern to recovery is confounded to some 
extent by age since the polydrug and marijuana 
groups contain a larger proportion of younger 
patients" (p. 31). 19 



18 This study reported on 83 individuals who responded to 
advertisements offering referral to cocaine treatment and who 
then self-selected a CD program, an outpatient program, or no 
treatment following an education/information session. The 
study found no significant differences between the CD and no- 
treatment groups eight months later. 



"Studies of Hazelden drug clients (Laundergan, 1982; Gilmore, 
1 985) are too limited methodologically to merit detailing, which 
is unfortunate, given the prominence of this program. The 
findings are consistent with CATOR and CareUnit results in 
indicating lower abstinence rates at follow-up for drug clients 
than for alcohol-only clients. 



734 



NIDA DRUG SERVICES RESEARCH SERIES, No. 2 



THE EFFECTIVENESS OF TREATMENT 



Why Do the Results of Chemical 
Dependency Treatment Vary? 

There are no useful studies that distinguish the 
reasons why some clients in CD programs recover 
and others do not. As with other treatments, client 
motivation and program staff quality are suspected 
factors. But there is no readily available 
information on variations in drug client outcomes 
across CD programs or any attempts to relate such 
differences to systematic variations among clients 
or in the therapeutic approach. 

Benefits and Costs of Chemical 
Dependency Treatment 

There are no studies available on the costs and 
benefits or cost-effectiveness of this modality. 
There is some discussion of cost data, however, in 
Chapters 6 and 8. 

DETOXIFICATION 

Detoxification, unlike the previous modalities, is 
not a treatment for drug-seeking behavior. Rather, 
it is a family of procedures for alleviating the 
short-term symptoms of withdrawal from drug 
dependence (NIDA, 1981, 1983b; Kleber, 1987). 20 
The major procedure is observation (because 
withdrawal is self-limiting and ordinarily not life- 
threatening, although it can be uncomfortable). 
There are some standard clinical indications for 
administering pharmacological agents during 
detoxification: to ameliorate severe withdrawal 
symptoms, to induce relaxation, to prevent 
seizures in the case of sedative-hypnotic drugs, 21 
or to counteract severe depression. 

20 Diagnoses of abuse ordinarily do not call for detoxification 
procedures, although in occasional cases of abuse there is 
reason for 2 to 24 hours of medical observation to monitor 
clearing of severe intoxication or acute overdose (possibly 
needing emergency intervention if vital signs are poor). These 
treatments of single episodes of excessive dosing may be 
thought of as logical counterparts to detoxification from 
dependence, but they are not detoxification. 

21 Detoxification of barbiturates is particularly liable to involve 
seizures and is more likely than other drug withdrawal to need 
management in a supervised environment-a hospital or other 
residential facility with appropriate medical staff and 
equipment. 



Detoxification of different drugs involves different 
durations and medications. Various 

pharmacological agents are used for withdrawal 
from opiate addiction, which has been extensively 
studied and reported for more than 60 years. The 
most common detox drug is methadone, but 
benzodiazepines, clonidine, and some other agents 
also are frequently used to control withdrawal 
symptoms. Opiate detoxification has often been 
done rather slowly— over several weeks or even 
several months—particularly in cases in which there 
is a long, continuous history of dependence. 
Today, however, new, more rapid forms of 
detoxification using combinations of drugs such as 
clonidine and buprenormine are being tested and 
used in residential and outpatient settings. 

Detoxification of cocaine, particularly crack- 
cocaine dependence, has been especially difficult, 
but some promising approaches are now emerging. 
Cocaine dependence typically involves a series of 
binges that last from 12 to 36 hours each. These 
binges are usually followed by several days 
without cocaine use but with gradually mounting 
withdrawal symptoms that include mood 
alterations, diminished capacities for experiencing 
pleasure (anhedonia), and craving for cocaine. 
These symptoms may not abate for four to eight 
weeks, thus yielding another binge cycle in very 
short order. The critical task in detoxification is 
to disrupt the imminent return of the cocaine 
cycle. 

There has been some success in the management of 
cocaine withdrawal symptoms and craving in 
ambulatory clinical trials using desipramine 
hydrochloride (Gawin et al., 1989a), amantadine 
(Tennant and Sagherian, 1987), bromocriptine 
(Dackis et al., 1987), flupenthixol decanoate 
(Gawin et al., 1989b), and buprenorphine (Mello 
et al., 1989), among other drugs, in conjunction 
with once-a-week outpatient counseling. These 
treatments reduced short-term rates of relapse two- 
to threefold for a majority of those treated. 
Unfortunately, most of these agents do not begin 
to have their major clinical effect for one to two 
weeks, during which outpatient dropout often 
occurs (in the programs in which trials have been 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER S 

conducted, dropout rates range from 30 to 70 
percent) . 

Comfort, the avoidance of seizures (the most 
common cause of fatalities), screening and 
treatment of infections and other medical 
problems, and the achievement of a condition in 
which withdrawal distress is not evident are and 
should be the primary goals of detoxification. In 
these terms, current detoxification procedures for 
most drugs are virtually always effective if they 
are completed, permitting a transition to abstinence 
with only attenuated symptoms of withdrawal. 
The key to completing detoxification successfully 
is compliance with the detox protocol: taking 
medication in prescribed amounts and schedules 
and avoiding intervening use of the drug on which 
the client is dependent and any other nonprescribed 
drugs. 

Inpatient or residential detoxification appears 
logically to offer better opportunities for clinicians 
to ensure compliance with detoxification 
prescriptions. There is little evidence, however, 
by which to judge whether this supposition is, 
indeed, true. Inpatient, residential, and outpatient 
drug detoxification have not been adequately 
compared to permit confident conclusions on 
which has the best compliance record or who 
belongs in which setting. On technical grounds, 
detoxification of most illicit drugs in most cases 
can occur as safely and effectively on an 
ambulatory basis as in a bedded setting. Hospital 
treatment in particular calls for justification on 
relevant medical grounds, such as history of 
seizures, concurrent conditions needing hospital 
care, or special cases of risk such as neonates of 
dependent mothers. On the basis of cost, an 
ambulatory detox is therefore preferable for most 
individuals when the medical criteria dictating 
inpatient detoxification are not present. These 
issues will be discussed further in Chapters 7 and 
8. 



Consistently, without subsequent treatment, 
researchers have found no effects from 
detoxification that are discernibly superior to those 
achieved by untreated withdrawal in terms of 
reducing subsequent drug-taking behavior and 
especially relapse to dependence. No appreciable 
success in increasing rates of recovery from heroin 
dependence after detoxification alone has been 
demonstrated for different pharmacological agents 
or for various detoxification protocols (e.g., rapid 
versus slow tapering of dose). Review articles 
reaching this decisive conclusion include those by 
Resnick (1983), Newman (1983), Cole and 
colleagues (1981), Moffet and coworkers (1973), 
and Sheffet and colleagues (1976). There is much 
less of a literature on cocaine detoxification, but 
clinicians who are experienced in treating opiate 
dependence do not believe that short-term 
detoxification alone will prove any more effective 
with cocaine. 

On the other hand, a detoxification episode offers 
clinicians a major opportunity to recruit clients 
into treatment, as the Bale team's study (1980) 
demonstrated (see also NIDA, 1981; Kleber, 
1987). Success at recruitment may well be a more 
critical outcome for detoxification programs than 
the conventional primary goals of comfort and 
suppressing withdrawal symptoms. There appear 
to be significant variations across U.S. cities in 
successfully enlisting detoxification patients into 
treatment. Discharge data from the 1980 CODAP 
report indicated that only 14 percent of opiate 
detoxification clients were transferred or referred 
to further treatment, although there was substantial 
variation around this average: out of 62 reporting 
areas, 12 had transfer/ referral rates lower than 5 
percent, and 14 had rates greater than 25 percent. 
There are no studies to indicate whether such 
variations relate to systematic differences in 
clients, the treatment process, or staff 
performance, or to chance. 



It is crucial to underscore the fact that the goals of 
detoxification are quite limited. This restricted 
scope is mainly a product of extensive experience 
with the lack of longer term effects of 
detoxification, especially of heroin dependence. 



136 



NIDA DRUG SERVICES RESEARCH SERIES, No. 2 



THE EFFECTIVENESS OF TREATMENT 



CORRECTIONAL TREATMENT PROGRAMS 

The overall record of research on prison-based 
drug treatment programs is moderate in scope, and 
the findings mostly correspond to the largely 
negative results observed in the treatment of 
criminals during incarceration in hopes of reducing 
their recidivism (Vaillant, 1988; Besteman, 1992; 
Chaiken, 1989). Yet Falkin and colleagues (1992) 
sound a more optimistic note: 

Given the current array of treatment programs (many 
offering only occasional counselling, drug education or 
other limited services), the finding of evaluation research 
that many programs are ineffective is not surprising. To 
adjudge that drug treatment is unable to control 
recidivism because many programs do not is to miss the 
crucial point that some programs have been quite 
successful. With the proper program elements in place, 
treatment programs could achieve a significantly greater 
reduction in recidivism than by continuing a policy of 
imprisonment without adequate treatment. 

Their list of the elements necessary for a 
successful prison drug treatment program 22 is 
succinct: 

■ a competent and committed staff; 

■ adequate administrative and material support 
by correctional authorities; 

■ separation from the general prison 
population; 

■ incorporation of self-help principles and ex- 
offender aid; 

■ comprehensive, intensive therapy aimed at 
the entire lifestyle of a client and not just the 
substance abuse aspects; and 

■ an absolute essential—continuity of care into 
the parole period. 



22 These elements could also apply to community programs, 
which is not surprising because many of the same clients are 
seen in both program settings. 



Three controlled evaluations of prison-based 
programs that incorporate these criteria are 
available and are discussed in the sections below. 
The first used three control groups: a group of 
program applicants (this was a voluntary program) 
who did not receive treatment for lack of timely 
openings— essentially a random selection process— 
and participants in two other kinds of treatment in 
the same prison system. The second study (also a 
voluntary program) used as controls an early- 
dropout group and an untreated group from the 
same prison system. The third study, sampling a 
very large prison/parole program with more than 
1,000 admissions per year (partially voluntary), 
used a sophisticated case-control matching 
procedure involving the early dropouts from the 
program. All three studies collected data on the 
entire group entering treatment for periods of 2 to 
1 1 years after release from confinement. Overall, 
the results indicate that sizable positive effects can 
be obtained from treatment, although the results 
are not unequivocal. 



Stay'n Out and Cornerstone 

The most recent and currently most influential 
study (see the discussion of Project REFORM in 
Falkin et al., 1992; also Frohling, 1989) is of 
Stay'n Out, a New York program that operates a 
four-unit, 146-bed prison program for male 
inmates and a separate 40-bed program for female 
inmates. The program is based on the social 
organization of a major therapeutic community, 
Phoenix House, and adapted to the prison setting; 
it works closely with community-based TCs to 
extend treatment contact after release. Stay'n Out 
clients from 1977-1984 (N = 682) were compared 
with similar groups of drug-abusing and dependent 
prisoners. The comparison groups received either 
regular drug abuse counseling (N = 576) or milieu 
therapy, which is a staff-intensive congregate- 
residential counseling approach or quasi-TC (N = 
364); there was also an untreated control group 
who applied and were waiting for Stay'n Out 
admission but who were not treated because there 
were not enough openings during their window of 
eligibility, the 6 to 12 months before their first 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1. CHAPTER 5 



TABLE 5.4 Results of Evaluation of Stay'n Out Prison Treatment Program (New York) 
Compared to Groups Receiving Other Treatment Modalities or No Treatment 



Group 


Percentage 
Re-arrested 


Average Months 
Before Re-arrest 


Percentage 
Reincarcerated 


Percentage Not 
Completing Parole 


(Number of 
Males/Females) 


Males" 


Females 


Males Females 


Males Females 


Males Females 


Stay'n Out 
therapeutic community 
(435/247) 


27 


18 


13 12 


44 


42 23 


Milieu (576/0} b 


35 


-- 


11 


45 


47 


Counseling (261/113) 


40 


30 


12 15 


41 


47 32 


No Treatment (159/38) 


41 


24 


15 9 


c c 


39 47 



"The differences in results in this column only are statistically significant beyond the .05 level (x 2 
p<.001). 

"Milieu therapy was not available to female prisoners. 
""Reincarceration data were not collected for these groups. 



= 172, 



Source: Falkin and colleagues (1991). 



138 



NIDA DRUG SERVICES RESEARCH SERIES. No. 2 



THE EFFECTIVENESS OF TREATMENT 



TABLE 5.5 Results of a Three-Year Follow-up of the Cornerstone Treatment Program 
(Oregon) Comparing Program Graduates, Program Dropouts, and Untreated Parolees 



Group 



N 



Percentage 

Newly 

Convicted 



Percentage 
Reincarcerated 



Graduates of the Cornerstone 
treatment program 



144 



46 



29 



Cornerstone dropouts 

(less than one month in program) 



27 



85 



74 



Combined Cornerstone groups 



171 



54 



36 



Untreated Oregon parolees with 
substance abuse histories 



179 



74 



37 



Source: Field (1984). 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



parole hearing (N = 197). The groups were 
followed through 1986 (i.e., from 2 to 9 years 
after release from prison). 

As indicated in Table 5-4, the TC group was 
arrested significantly less often than the other 
groups, with differences of 8 to 14 percentage 
points (which represent 22 to 35 percent reductions 
in rearrest rates) for men and 6 to 12 percentage 
points (25 to 40 percent reductions) for women. 
Because for every arrest, such criminally inclined 
individuals have generally committed hundreds of 
crimes (Ball et al., 1981; Johnson et al., 1985; 
Speckart and Anglin, 1986), these differences in 
rearrest rates are a valuable result. The authors 
indicate, however, that intergroup differences at 
follow-up in rates of reincarceration, rapidity of 
rearrest, and parole revocation were statistically or 
substantively negligible, except that significantly 
more Stay'n Out-treated women than untreated 
women successfully completed their parole term. 

A similar controlled observational study of the 
Cornerstone program has been reported by Field 
(1984, 1989; see Table 5-5). Cornerstone is a 
modified TC program (a mixture of milieu therapy 
and TC principles) located in Oregon State 
Hospital in Salem. It is designed for state 
prisoners in the last year prior to eligibility for 
parole; after release, the parolees move to a 
halfway house that includes some therapeutic 
contacts. Study results indicate that prisoners in 
the program were convicted significantly less often 
than comparable parolees in the three years 
following release. 23 



23 The net figure in Table 5-5 for the whole Cornerstone group- 
that is, the 54 percent who were convicted of new crimes after 
release-is the yield within the combined group of dropouts 
(less than one month in the program) and graduates. In private 
communications with the Cornerstone staff, the committee was 
told that most dropouts from the program leave within the first 
few weeks; therefore, ignoring the small numbers who dropped 
out between the first month and graduation, for whom follow- 
up data have not been published, would not appreciably modify 
the above result. Those in the parolee comparison group, 
according to Field (1984:54), "do not have the chronic 
substance abuse histories nor the chronic criminal histories of 
Cornerstone graduates [and therefore] would be expected to do 
better at avoiding criminal recidivism than Cornerstone 
graduates-execpt, of course, for the treatment results." 



Graduates of Cornerstone did much better at 
follow-up than early dropouts from the program. 
In the Stay'n Out study, and in several other well- 
regarded, well-studied voluntary correctional 
programs (see Falkin et al., 1992), length of stay 
in treatment correlated strongly with positive 
follow-up measures, the same result seen in 
community -based programs. The fact that early 
dropouts from prison programs are even more 
likely to recidivate, by every measure, than are 
untreated controls suggests that prison-based TCs 
may be more efficient than community-based 
programs at sorting out and excluding (or 
encouraging self-exclusion of) the poorest 
responders. 



The California Civil Addict Program 

A different type of correctional treatment program 
combines treatment in a penal institution with 
specialized parole supervision, including access to 
a variety of community-based treatment 
opportunities. The most comprehensive and well- 
studied example of this kind of program was CAP, 
the California Civil Addict Program, which began 
in 1961 (McGlothlin et al., 1977; Anglin and 
McGlothlin, 1984; Anglin, 1988). Two similar 
civil commitment programs, one federal and one 
operated by the state of New York, fell far short 
of their design goals, ended fairly quickly, and 
were roundly regarded as failures (Besteman, 
1978, 1992; Inciardi, 1988). Even the CAP effort 
operated as designed only until 1969, after which 
much of its original character was lost, principally 
because the strict therapeutic rationale was 
overturned by the general fiscal leanness and 
operational leniency that overtook the California 
penal system during then-Governor Ronald 
Reagan's second term. In addition, community- 
based treatment programs funded largely by the 
federal government became available after 1970, 
creating attractive treatment alternatives for 
criminal justice agencies and clients. As discussed 
earlier, this expansion of treatment coincidentally 
presented a research opportunity to compare the 
results of the correctional treatment program and 
methadone maintenance. 



740 



A/IDA DRUG SERVICES RESEARCH SERIES, No. 2 



THE EFFECTIVENESS OF TREATMENT 



TABLE 5.6 Comparison of Types and Strength of Evidence on Effectiveness, Number 
of Admissions, and Revenues for the Major Drug Treatment Modalities 



Element 



Treatment Modalities 



Methadone Therapeutic Outpatient Chemical 

Maintenance Communities Nonmethadone Dependency 



Evidence of effectiveness" 



Randomized clinical trials 
Quasi-experiments b 
Controlled observations 
Simple observations 6 

Annual number of admissions 
(in thousands) 9 

Annual Revenues 
(in millions of dollars) 8 



*• 

* * 

* * * 

** * 



130 



200 



110 



200 



* * 
* * * 



430 



300 



140 



500 



"* = A single study of this type; ** = a few such studies; *** 
varied study designs; -- = no such studies conducted. 

b 



= studies of numerous programs with 



For example, the introduction of a new treatment modality, a program closing, or an incompletely 
randomized trial that used multivariate analysis. 

°Studies of treatment cohorts, usually including treatment refusals and using multivariate analyses. 

d Studies of single treatment cohorts without nontreatment comparisons and using only univariate of bivariate 
analyses. 

"The source of these modality statistics is the Institute of Medicine analysis of the 1987 National Drug and 
Alcoholism Treatment Utilization Survey (see Chapter 6 for discussion of these admission and revenue 
estimates). 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



CAP permitted adjudication of heroin-dependent 
individuals through a civil commitment procedure 
rather than regular criminal sentencing. 24 The first 
(repeatable) stop for CAP clients, once they had 
been committed, was a term in the California 
Rehabilitation Center at Corona, a medium- 
security prison with a large staff of psycho- 
therapists. This period began a seven-year term 
of supervision, three-fourths of which, on 
average, was spent on parole in the community 
rather than in the center. (The seven-year 
commitment term could be terminated after three 
consecutive drug-free years in the community.) 
The community supervision component involved 
specially trained parole officers, smaller caseloads 
of only 30 parolees, and weekly drug testing 
(Anglin, 1988). 

The conditions conducive to a case-control study 
were inadvertently created during the initial years 
of the program. The original commitment law was 
complex enough that legal-procedural errors were 
made in committing at least half of the early CAP 
clients. Sooner or later, most of these 1961-1963 
commitments were challenged by writs of habeas 
corpus, and the individuals were released by court 
order from CAP incarceration and supervision and 
returned to the regular track of criminal adjudi- 
cation, with credit for the time served during CAP. 
The overall writ-released group differed from those 
who continued in CAP in that many writ-releasees 
had less serious offenses for which the CAP 
commitment of seven years was a longer term than 
the sentence (including parole or probation) they 
would probably otherwise have served. On the 
other hand, virtually all of the continuing CAP 
group would probably have had longer sentences 
without the CAP diversion. The researchers 
therefore used matching procedures to select from 
within the writ-released group a comparison sample 
that was as similar as possible to the continuing 
group on 15 criteria, including criminal and drug 
histories and demographic characteristics. 

24 As at Lexington, voluntary as well as criminal commitments 
to the facility were permitted. Most CAP clients, however— 
about 70 percent before 1970 and 93 percent afterward-had 
been convicted of felonies, largely for nondrug offenses such 
as burglary and robbery. In addition, before 1970, about 15 
percent had been referred by police officers on the noncriminal 
basis of "believed addicted." 



During their years under CAP, individuals 
retrospectively reported that they reduced their 
heroin use (Figure 5-6) as well as total criminality 
while unincarcerated to levels that were half or less 
than half the amount reported by the comparison 
group. These reductions became apparent 
immediately after their release into the community, 
and they were sustained. The difference between 
CAP parolees and the comparison group on these 
dimensions narrowed over the next several years as 
more members of the writ-released group (some of 
them recommitted to CAP for new offenses) 
reduced their heroin use and other criminal 
behavior. By the time the continuing CAP group's 
parole ended, the control group was at a more 
nearly similar level, especially considering 
pretreatment (baseline) differences. The 

subsequent recovery paths of the two groups 
remained parallel. 

In summary, the residential and community 
supervision components of CAP were evidently 
effective in accelerating the recovery of a 
significant fraction— at least half— of the treated 
group. 

A different result of the CAP study was to examine 
the effects of methadone maintenance treatment 
during CAP supervision (Anglin et al., 1984). In 
1971, as discussed earlier in the chapter, 
methadone programs were opened in a number of 
California's cities, and some members of both the 
CAP and the writ-released comparison group who 
had continued active heroin use elected to enter 
methadone programs. (Parole officers neither 
insisted on this option nor opposed it.) In both 
samples, entry to methadone had powerful effects 
on individuals who, by and large, had not 
otherwise begun recovery— effects as great or 
greater than those of CAP parole itself (Figure 5- 
7) . There were no significant differences between 
the CAP and the comparison group in how 
methadone affected their heroin-seeking or other 
criminal behavior. 

Boot Camps 

A final type of prison-based treatment that has 
received much attention recently is the "boot 



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THE EFFECTIVENESS OF TREATMENT 



Q 
111 

r- 

QC-J 
ui< 
Oq 

<co 

GO 
Zh 
ZO 

°°- 

t< 

o z 

si 

Z.JLI 
LUg 

QS= 
CCH- 

111 
CL. 



100 



= 80 



60 



40 




Premethadone 



Postmethadone 



non-CAP 




8 642M2 46 

YEARS 



FIGURE 5-7 The effect of methadone maintenance on daily narcotics use in the California Civil Addict 
Program and control groups. The percentage of nonincarcerated time during which subjects reported 
using narcotics daily is shown for 8 pre- and 6 postadmission years. The vertical line at M denotes 
admission to methadone maintenance treatment. The CAP group (N = 136) entered treatment for the 
first time while on parole status under the California Civil Addict Program; the non-CAP or control 
group (N = 136) were first-treatment admissions who were not in the Civil Addict Program. 

Souro*: AngHn at al. (1981). 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



camp" or "shock incarceration" (SI) concept for 
young offenders. This treatment constitutes a 
three- to six-month sentence for young offenders 
who are remanded to a facility employing rigorous 
physical exercise and a small-group organizational 
structure similar to Outward Bound or military 
training camps. A number of states, beginning 
with Georgia in 1983, have opened such facilities, 
largely as a way to reduce prison costs and 
improve resource management. Shock 

incarceration segregates young offenders, who 
would otherwise be mixed with the general 
penitentiary population (in this case, SI reduces 
penitentiary overcrowding) or with the general 
probation population (in this case, using the SI 
option increases the need for correctional 
facilities) . 

There are several studies under way to improve 
understanding of how these programs work. Boot 
camps vary in nature. Some are entirely 
militaristic environments with few if any 
therapeutic staff or procedures; others incorporate 
many drug treatment elements that the more 
successful prison treatment efforts display but lack 
still other requirements— particularly continuity of 
care when the individual returns to the community. 
Parent (1989:4,5), in a report to the National 
Institute of Justice, summarizes current knowledge: 

Preliminary case tracking data raises questions 
about Si's capacity to reduce recidivism. The 
Oklahoma Department of Corrections used survival 
analysis to compare return rates of SI graduates 
with similar non-violent offenders sentenced to the 
DOC. After 29 months almost half the SI 
graduates, but only 28 percent of the other group, 
had returned to prison. 

In a three year follow-up, the Georgia DOC found 
that 38.5 percent of their SI graduates returned to 
prison. For Georgia SI graduates who were in 
their teens when admitted to SI, 46.8 percent 
returned to prison within three years of release. 
In an earlier study, Georgia researchers found 
little difference in one-year return to prison rates 
for SI graduates, and similar offenders sentenced 
to prison and to a youthful offender institution. It 
should be emphasized that neither of these studies 
involved carefully constructed comparison groups. 



Until evaluation results become available, policy 
makers should view claims of incredible success 
with skepticism, and should be cautious about 
proceeding with SI development on the basis of 
high hopes, preliminary data, or press clippings. 



Conclusions about Prison Treatment 



Prisoners with drug problems are "hard cases," but 
in terms of avoidable social damage, success in 
accelerating the recovery of even a modest 
proportion of them yields substantial social 
benefits. The limited research information on 
correctional treatment indicates that some 
programs have delivered this benefit, but many 
have not. The research does not clearly 
demonstrate why only a few prison programs have 
curbed recidivism, but clinical judgments about the 
key differences between effective and noneffective 
programs are consistent with the available evidence 
and bear repeating here. 

First, clients need not be dragooned into treatment 
in order to enlist substantial participation in 
correctional programs. In the three programs 
reviewed here in detail, and in most well-regarded 
programs, entry has largely been a matter of 
negotiation or multilateral consent, requiring the 
fulfillment of certain obligations by the prospective 
client, program staff, and custodial authorities. 
The principal requirement for effective correctional 
treatment programs is responsiveness: the 
program must respond to individual client 
behaviors as surely as the individual must respond 
to clinical protocols and queries. The treatment 
programs have had authority to exclude clients. 
Mutual consent and performance are a recurrent 
theme, evident in the formulation of entry 
contracts and treatment plans, the incorporation of 
self-help principles and systems of earned program 
privileges, and roles for program graduates. 

Successful correctional treatment requires clinically 
skillful staff who are strongly committed to their 
work. To maintain staff skills and commitment in 
the face of difficult cases is impossible without 
adequate material and administrative support from 



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correctional and other authorities. Another vital 
element is follow-up research to let staff know 
what effects their efforts are having. 

Treatment is not an alternative to penalties for 
committing violent and acquisitive crimes such as 
robbery, burglary, and larceny, for which 
offenders with drug problems are so frequently 
apprehended. Treatment decisions (including 
admission and termination) need to be made on 
therapeutic grounds in terms of program goals and 
rules; decisions in the interest of justice and 
custodial security must also be made by the 
appropriate authorities on their own merits. But 
decisions in either sphere must be consistent with 
explicit rules, and agencies must be prepared to 
follow through on them. Contingencies such as 
revocation and return to custody in the event of 
noncompliance with release conditions must be 
believable and consistently enforced. 



SUMMARY AND CONCLUSIONS ABOUT 
TREATMENT EFFECTIVENESS 

The committee is both satisfied and disappointed 
with the conclusions that can be drawn about the 
effectiveness of the major drug treatment 
modalities. It is satisfied that some modalities 
have been studied with sufficient skill and 
methodological integrity that conclusions can, 
indeed, be drawn (even though there is still much 
to be desired in the way of useful knowledge). It 
is disappointed that the same cannot be said of 
other modalities and that the overall state of 
knowledge about treatment effectiveness has not 
grown more rapidly in the past 5 to 10 years. 
Most of what is known is based on data collected 
between 1969 and 1981. 

Table 5-6 is a succinct statement of this 
disappointment. Of the four major modalities, 
methadone maintenance has received the most 
extensive study, using all of the main types of 
treatment evaluation research techniques. 
Therapeutic communities have received the next 
most extensive assessment; outpatient 
nonmethadone treatments have been evaluated at a 



somewhat lower level. Chemical dependency 
treatment has the least extensive useful body of 
knowledge concerning its effectiveness. 25 Yet 
according to the committee's analysis of a 1987 
national survey of drug treatment providers 
(detailed in Chapter 6), the order of expenditures 
for these modalities is exactly the reverse of the 
order of knowledge about their effectiveness. 

In the final section of this chapter, the committee 
offers its ideas on how to go about repairing the 
sources of its disappointment. These ideas are 
presented as a series of specific research 
recommendations. First, however, the committee 
summarizes below its findings about the respective 
modalities. 

Methadone Maintenance 

Methadone maintenance is a treatment for 
extended opiate dependence (which is usually 
heroin). A sufficient daily oral dose of methadone 
hydrochloride, which is a relatively long-acting 
narcotic analgesic, yields a stable metabolic level 
of the drug. Consumption once daily of a stable, 
clinically adjusted dose is not behaviorally or 
subjectively intoxicating and does not impair 
functioning or generate appreciable morbid side 
effects. Once a newly admitted client reaches a 
stable, noneuphoric "blockade" state, free of the 
psychophysiological cues that precipitate opiate 
craving, he or she is amenable to counseling, 
environmental changes, and other social services 
that can help shift his or her orientation and 
lifestyle away from drug seeking and related crime 
toward more socially acceptable behaviors. 

Methadone maintenance has been the most 
rigorously studied modality and has yielded the 
most incontrovertibly positive results. However, 
it is also the most controversial treatment, largely 
on the grounds that methadone clients 



2E Correctional treatment has not been included on this chart 
because it is not a distinct modality. Knowledge about prison- 
based programs is approximately at the same level as that for 
community-based TCs. Detoxification also is not included 
because it is not considered a treatment for drug-seeking 
behavior in the same way as are the major modalities. 



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have "merely" switched their dependence to a legal 
narcotic and that some clients (the proportion 
varies from program to program) continue to take 
heroin and other drugs intermittently and to 
commit crimes, including the sale of take-home 
methadone. In the committee's judgment, these 
controversies and reservations are neither trivial 
nor compelling. The great majority of methadone 
clients had been consuming high levels of illicit 
drugs and committing other crimes (including drug 
selling) on a daily basis prior to admission. The 
issues are to what extent undesirable behaviors are 
reduced and positive behaviors increased as a 
result of methadone maintenance (in comparison to 
no treatment or to alternative measures), and 
whether enough is known about such treatment to 
improve poorly performing programs. 

Research on methadone has demonstrated the 
following: 

■ There is strong evidence from clinical trials 
and similar study designs that, on average, 
heroin-dependent (or other opiate-dependent) 
individuals have much better outcomes in 
terms of illicit drug consumption and other 
criminal behavior when they are maintained 
on methadone than when they are not treated 
at all, when they are simply detoxified and 
released, or when methadone is tapered down 
and terminated arbitrarily. 

■ Methadone clinics have significantly higher 
retention rates among opiate-dependent 
populations than do other treatment modalities 
for similar clients. 26 

■ When assessed following discharge from 
methadone treatment, clients who stayed in 
treatment longer have better outcomes than 
clients who left earlier. 



2e lt should be noted that higher retention can "load the dice" 
when making outcome comparisons during treatment among 
different modalities. Because dropouts generally show worse 
behavior and have somewhat poorer prognoses to begin with, 
a program that retains more of its initial clients, even if equal 
in its effect on each client, will have a lower average 
effectiveness on clients remaining in treatment. The bias fades 
if all admissions, not only the ones remaining in treatment, are 
compared across modalities. 



Methadone dosages need to be clinically 
monitored and individually optimized. 
Clients do much better, however, when they 
are stabilized on higher rather than lower 
doses within the typical ranges that are 
currently prescribed (30-100 mg/day). 
Program characteristics such as inadequate 
methadone dosage levels and differences 
between counselors (which are not yet fully 
defined) are significantly related to 
differences in client performance while in 
treatment. 

Methadone treatment, when implemented at 
the resource levels observed in the late 
1970s, provides individual and social benefits 
over a term of at least several years that are 
substantially higher than the cost of delivering 
this treatment, which is now $3,000 per year 
and which should be at least $4,000 per year 
to be comparable to earlier programs. The 
daily benefits equal the daily costs in virtually 
every case, even among those who continue 
drug taking at a lower level. 



Therapeutic Communities 

Therapeutic communities are residential programs 
with expected stays of generally 9 to 15 months, 
phasing into independent residence with continuing 
contact for a variable period. TC programs are 
highly structured blends of resocialization, milieu 
therapy, behavioral modification practices, 
progression through a hierarchy of occupational 
training and responsibility within the TC, 
community reentry, and a variety of social 
services. 

Therapeutic community clients are more diverse in 
their drug use patterns than methadone clients 
because the modality is not specific to any 
particular class of drugs. From the 1960s to the 
early 1980s, a majority of TC clients were 
primarily dependent on heroin. In the late 1980s, 
cocaine dependence began to predominate in many 
programs. Therapeutic communities are designed 
for individuals with major impairments and social 
deficits, including histories of serious criminal 



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behavior. The results of research on the effects of 
TC treatment are as follows: 



TC clients end virtually all illicit drug taking 
and other criminal behavior while in 
residence and perform better (in terms of 
reduced drug taking and other criminal 
activity and increased social productivity) 
after discharge than before admission. They 
also have better outcomes at follow-up than 
individuals who simply underwent 
detoxification or who contacted but did not 
enter a TC program. The length of stay is 
the strongest predictor of outcomes at follow- 
up, with graduates having the best outcomes 
at that point. 

Attrition from TCs is typically high—above 
the rates for methadone maintenance but 
below the rates for outpatient nonmethadone 
treatment. Typically, about 15 percent of 
admissions will graduate after a continuous 
stay; the figure is higher (20 to 25 percent) 
once later readmissions are considered. 

The minimum retention necessary to yield 
improvement in long-term outcomes seems to 
be several months, which covers one-third to 
one-half of a typical program's admissions. 
Improvements continue to be manifested for 
full-time treatment of up to one year in 
length. 

The benefits of TC treatment are substantial 
and they virtually repay the costs on a day- 
by-day basis, although the per diem costs are 
higher than for methadone maintenance: 
generally, about $13,000 per year— probably 
$20,000 for a model program— yielding 
somewhat lower benefit/cost ratios than for 
methadone but ones that still favor the use of 
this treatment. 



Outpatient Nonmethadone Programs 

Outpatient nonmethadone programs display a great 
deal of heterogeneity in their treatment processes, 
philosophies, and staffing. Their clients generally 
are not opiate dependent but otherwise vary across 
all types of drugs. Usually, OPNM clients have 
much less serious criminal histories than 
methadone or TC clients and include more 
nondependent individuals. Outpatient 

nonmethadone programs generally provide one or 
two visits per week for individual or group 
psychotherapy/counseling, with an expected course 
averaging about six months. 

Despite the heterogeneity of programs and their 
clients, the limited number of outcome evaluations 
of OPNM programs have generated conclusions 
qualitatively similar to those from studies of TCs: 



Outpatient nonmethadone clients during and 
following treatment exhibit better behavior 
than before treatment. Those clients who are 
actually admitted to programs have better 
outcomes than clients who contact but do not 
enter programs (and clients who only undergo 
detoxification). Outcome at follow-up is 
positively related to length of stay in 
treatment, and completers have better 
outcomes than dropouts. 

Retention in outpatient nonmethadone 
programs is poorer than for methadone 
maintenance and therapeutic communities. 

The benefits of OPNM treatment are fewer 
than for methadone or TCs, but the cost of 
the treatment, at about $1,350 for six months 
(about $1,800 for a model program), is low. 
As a result, the yields are favorable for those 
who stay longer than three months, and the 
aggregate program ratios are mildly 
favorable. 



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Chemical Dependency Programs 

Chemical dependency programs generally are 
residential or inpatient, with a three- to six-week 
duration, followed by up to two years of 
attendance at self-help groups or a weekly 
outpatient therapy group. CD programs are based 
on an Alcoholics Anonymous (12-step) model of 
personal change, a belief that dependence is a 
permanent but controllable disability, and goals of 
total abstinence and lifestyle alteration. The 
proportion of the CD population who are drug 
involved is similar to the outpatient nonmethadone 
population in that the primary drugs are cocaine 
and marijuana. The modal CD client, however, is 
an older, socially well-supported, alcohol- 
dependent individual. 

CD programs are often located in hospitals, but the 
core therapeutic elements of this modality do not 
require the presence of acute care hospital 
services. There is little evidence on whether 
hospital-based CD programs are more or less 
effective for drug problems than CD programs that 
are not sited in hospitals, or whether they are more 
or less effective than no treatment at all. Chemical 
dependency programs treat mainly primary 
alcoholism and have not been adequately evaluated 
for treatment of drug problems. A few follow-up 
studies of individuals who have completed CD 
treatment indicate that primary drug clients have 
poorer outcomes than primary alcohol clients. 
There are no cost/benefit analyses for chemical 
dependency treatment. 

Detoxification 

Detoxification is therapeutically supervised 
withdrawal to abstinence over a short term— that is, 
up to several months but usually five to seven 
days, often employing pharmacological agents to 
reduce client discomfort or the likelihood of 
complications. Detoxification is seldom effective 
in itself as a modality for bringing about recovery 
from dependence, although it can be used as a 
gateway to other treatment modalities. 

Clinicians generally advocate that detoxification 
not be considered a modality of treatment in the 



same sense as methadone, TCs, outpatient 
counseling, and CD units because of its narrow, 
short-term focus and poor outcomes in terms of 
relapse to drug dependence. 

Detoxification episodes are often hospital based 
and may begin with emergency treatment of an 
overdose. Much drug detoxification (an estimated 
100,000 admissions annually) is now taking place 
in hospital beds. It is doubtful whether 
hospitalization (especially beyond the first day or 
two) is necessary in most cases, except for the 
special problems of addicted neonates, severe 
sedative-hypnotic dependence, or concurrent 
medical or severe psychiatric problems. For 
clients with a documented history of complications 
or flight from detoxification, residential 
detoxification may be indicated. Detoxification 
may, in the committee's judgment, be undertaken 
successfully in most cases on a nonhospital 
residential, partial day care, or ambulatory basis. 

Correctional Treatment 

Treatment of drug-involved prisoners is fairly 
common, but at least two-thirds of prison 
treatment programs are equivalent to outpatient 
nonmethadone treatment— that is, periodic 
individual or group therapy sessions. This level of 
intervention is probably not intensive enough to do 
much for this group. The other prison treatment 
programs are similar to stays in a therapeutic 
community, including separation from the general 
prison population for the expected 6- to 12-month 
duration of the program. 

Most of the prison drug treatment programs that 
have been studied, including specialized "boot 
camp" or "shock incarceration" facilities, have not 
been shown to reduce the typically very high post- 
release rates of recidivism to drug seeking and 
other criminal behavior that occur among untreated 
prisoners. Nevertheless, a small number of well- 
designed controlled studies, involving prison TCs 
and residential programs that have strong linkages 
to community-based supervision and/or treatment 
programs, indicate that prison-initiated treatment 
can reduce the treated group's rate of rearrest by 
one-fourth to one-half; clear correlations are 



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THE EFFECTIVENESS OF TREATMENT 



observed between positive outcome rates and 
length of time in treatment, just as in studies of 
entirely community-based modalities. The results 
have some anomalies and there have been 
difficulties in sustaining the integrity of prison- 
based treatment programs, but the results argue 
that these programs should be carefully 
encouraged. 



If a single phrase could succeed in capturing most 
of the findings in this chapter, it would be an 
expression that—much like the current treatment 
modalities—dates from the 1960s: different strokes 
for different folks. No single treatment "works" 
for a majority of the people who seek treatment. 
Each of the treatment modalities for which there is 
a baseline of adequate studies can fairly be said to 
work for many of the people who seek that 
treatment; and enough of them do find the right 
treatment, and stay with it long enough, to make 
the current aggregate of treatment programs 
worthwhile. 

Selection of the most appropriate treatment 
modality by clients or others (e.g., judges, 
probation officers, employee assistance counselors, 
family members) is constrained by poor 
information about programs, location/ 
transportation issues, waiting lists at some portals 
and aggressive recruitment at others, and cost 
questions. In most locations, there is no 
comprehensive intake (assessment and referral) 
unit or agency to advise or assign applicants. 
(This triage feature, which was relatively common 
in the multimodality programs and municipal 
treatment agencies of the 1960s or 1970s, was 
often abandoned in the cost-cutting of the early 
1980s.) Most of all, the search for the right 
program is bedeviled by variations in program 
quality. The signs of poor program performance 
(particularly of poor response to the prospective 
client's specific set of problems) are not readily 
apparent, and the general lack of reliable 
information about program outcomes does not 
offer incentives for programs to change for the 
better. 



There is a great deal of room for improvement, 
and there are indications in the research literature 
on how to bring that about. Much of Chapters 7 
and 8 is informed by the committee's reading of 
those indications. Before moving to the final third 
of the report, however, the committee considers it 
vital to lay out a plan for restocking and expanding 
the limited store of knowledge it has had to draw 
on so that if another group is charged with 
studying the treatment system 5 or 10 years from 
now, they will not have to be as disappointed as 
this body was about the knowledge gains in the 
intervening years. The last section of this chapter 
therefore presents a brief but systematic template 
of recommendations for a national program of 
treatment research. 

RECOMMENDATIONS FOR RESEARCH 

ON TREATMENT SERVICES AND 

METHODS 

Rebuilding the Research Base 

Federal support for drug research, including 
research on treatment methods and services 
(alternatively, clinical and services research), 
surged during the early 1970s, declined steadily in 
real terms for the next decade, and began to surge 
again as a result of the Anti-Drug Abuse Acts of 
1986 and 1988 and recent initiatives for AIDS- 
related research (Figure 5-8). Unfortunately, but 
quite predictably, the base of capable researchers 
declined during the decade-long period of 
stagnation, as scientists moved on to other fields 
and very few new ones entered the drug research 
area. The number of centers of excellence in 
treatment-oriented research— active programs 
generating sound new results on current data- 
declined substantially; where there were formerly 
close to two dozen, located in all parts of the 
country, there are now just a handful in a few 
major metropolitan centers. 

The national research infrastructure must be rebuilt 
and the number of local centers of excellence in 
research on treatment methods and services 
increased to reverse the shortage of experienced 
investigators. Current funding increases are 



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sufficient to rebuild the needed base of treatment 
research excellence but only if the current level is 
sustained for at least four or five years and 
expenditures are patterned during that time to 
ensure attention to the perennial questions that face 
clinicians and policymakers responsible for the 
system. It is critical that this base be maintained 
through a program of steady incremental funding 
changes and not be dismantled once again, a 
course that would leave the nation unprepared to 
respond quickly to whatever new epidemic of drug 
use might arise in the future— and the lesson of 
history is that some new wave will arise. 

To evaluate and improve the adequacy and 
effectiveness of treatment plans and expenditures, 
the national services research program in particular 
needs rebuilding. The prospects for maintaining 
and improving treatment quality as well as 
continuing to develop more effective treatment 
methods depend to a great extent on treatment 
services research. The National Institute on Drug 
Abuse (NIDA), the agency most responsible for 
maintaining treatment research, is, of course, not 
autonomous. Its budget and priorities are 
proposed by the President and disposed by 
Congress. Moreover, providers of drug treatment 
services are very much at fault for permitting and 
in some cases tacitly encouraging the paucity of 
treatment research over the past decade. Programs 
have been characterized too much by a fear of 
failure and too little by the courage of their 
convictions. The results of earlier treatment 
enterprises tell an enlightening and reasonably 
heartening tale, and there is little possibility of 
improving current therapeutic practices further 
without careful study of outcomes, not only in 
research units, with their limited patient protocols 
and cadre of university-based researchers, but also 
in all other treatment programs. 

Most importantly, the advances in knowledge that 
came out of clinical and services research in the 
1970s have not been followed up, and as a result 
analysts today are not better prepared to answer 
questions about the effectiveness, costs, and 
benefits of current treatment than they were a 
decade ago. Data systems and analytic capabilities 
that were designed to answer policy questions have 



not been well maintained. It would be a travesty 
of prudent governance if once again the federal 
government and the states were to proceed to 
build, or rebuild, a major instrument of national 
drug control policy without assuring themselves 
and the taxpayers that there would be timely, 
necessary research and evaluation to understand 
that instrument's performance and facilitate its 
improvement. 

One more note needs sounding in this context. A 
critical longer term role is played by basic 
epidemiological, behavioral, biological, and 
neurochemical research to address such issues as 
the role of genetic predispositions in addiction, the 
factors that contribute to the plasticity of addictive 
behavior, the effects of social factors, and methods 
for reducing drug craving. The goal of such work 
should be to integrate the biological and behavioral 
sides of the drug problem. This integration will 
remain difficult so long as a continuing imbalance 
persists between substantial investments in 
high-quality biomedical research and meager ones 
in high-quality biobehavioral and psychosocial 
research. 

Major Research Questions 

The core questions that need to be addressed for 
the various modalities of public treatment are 
the following: What client and program factors 
influence treatment-seeking behavior, treatment 
retention and efficacy, and relapse after 
treatment? How can these factors be better 
managed? Treatment-seeking factors include 
community outreach, health promotion and disease 
prevention efforts such as experimental needle- 
exchange programs, family and employer 
interventions, and program intake and triage 
procedures. Retention and efficacy factors include 
optimal treatment durations and schedules, 
pretreatment motivations, counselor or therapist 
behavior, incentives and conditions of 
employment, clinic procedures, criminal justice 
contingencies, and ancillary services. 
Posttreatment factors include relapse prevention 
interventions, abstinence monitoring, and 
environmental reinforcement. 



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The questions need to be attacked in a variety of 
ways. Despite the difficulties of maintaining the 
integrity of controlled experiments in treatment 
programs, these studies provide the most 
incontrovertible evidence about comparative 
treatment effects, and efforts to conduct them 
should be strongly encouraged. A more detailed 
understanding of treatment processes through 
ethnographic and case study methods is also badly 
needed. This work is the basis for the design and 
interpretation of survey instruments. Studies 
should be initiated within as well as across each 
major treatment modality to answer the 
following question: What are the relations of 
treatment performance (that is, differential 
outcomes, taking initial client characteristics 
into account), the content and organization of 
treatment (specific site arrangements, service 
offerings, therapeutic approaches, staffing 
practices), and the costs of treatment? 

Services Research 

Health services research is a critical element in 
building treatment systems. An important 
foundation for services research as well as 
program accountability is the development, 
maintenance, and analysis of a system of data 
acquisition on treatment programs, client 
performance, and costs. Results from studies that 
use these kinds of data will permit better and more 
cost-effective decisions about facility 
characteristics, staff salary and training levels, 
services coordination methods, intensity of 
services, reasonable charges, and other 
components. Systems of this sort were established 
in the 1970s but were effectively disassembled as 
a matter of federal policy in the 1980s. 
Treatment data acquisition systems must be 
rebuilt and effectively managed and utilized if 
the improvement of treatment knowledge and 
practice is to be evaluated and facilitated in the 
1990s. Data on treatment effectiveness and 
costs should become the cornerstone of decisions 
about treatment coverage by public and private 
programs. 



NIDA, in conjunction with its sister agency, the 
Office of Treatment Improvement, needs to give 
more adequate, focused attention to the drug 
treatment delivery system as a whole. Stronger 
services research programs at NIDA are a critical 
complement to the research and service 
responsibilities of the Alcohol, Drug Abuse, and 
Mental Health Administration (ADAMHA). 
Fulfilling this responsibility requires close linkages 
to practice and thus some responsibility to and for 
service delivery. Existing legislative authority 
directing these linkages should be implemented 
fully. 

The responsibilities for research coordination, 
however, do not stop at the boundaries of 
ADAMHA. Collaborative and coordinative 
arrangements with the National Institute of Justice, 
the Bureau of Justice Statistics, the National 
Institute of Corrections, and other relevant 
agencies in the Department of Justice and other 
federal departments should be extended beyond 
current levels. More extensive relationships would 
encourage critical technical improvements, such as 
the inclusion in epidemiological and treatment 
surveys of "linkage" items to facilitate syntheses 
with data from criminal justice populations. For 
example, treatment applicants should be asked how 
many emergency room admissions and arrests they 
have undergone during the year prior to treatment, 
which would not only serve to build baseline data 
for outcomes research but also provide calibrations 
with respect to the Drug Abuse Warning Network 
and Drug Use Forecasting data systems. 

Some of the most compelling results of treatment 
research have come from large longitudinal studies 
involving thousands of clients: the DARP (Drug 
Abuse Reporting Program) study of a 1969-1971 
national admission cohort, which included a 
12-year follow-up, and TOPS (the Treatment 
Outcome Prospective Study), which involved a 
10,000-person national sample of 1979-1981 
admissions to 41 drug treatment programs in 10 
cities. There is reason to believe that some 
findings about the treatment modalities— such as the 
importance of time in treatment— will prove robust 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



151 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 5 



in the face of changing drug markets, but others 
may not. 

Another such national treatment sample study 
(DATOS, or the Drug Abuse Treatment Outcome 
Study) is beginning in 1990, and some smaller 
scale studies, such as the Drug Services Research 
Survey, are in process. Intervals of 10 years 
between entry cohorts to major studies as 
important as these are far too long. New study 
panels composed of 3-year entry cohorts (an 
efficient period of admission to a multiwave 
design) should begin at no greater than 5-year 
intervals. 

The responsibility to study treatment services in 
the field generally is not met by demonstration 
grant programs. Demonstrations have historically 
functioned as a stop-gap measure to provide a new 
kind of service for which there seemed to be a 
need but no certain knowledge about how to fill it- 
-knowledge lacking at least in part because 
adequate research systems were not already in 
place to generate it. Demonstrations are not a 
reasonable substitute for a strong program of 
treatment services research. Demonstration grants 
should be made only when objectives are carefully 
specified and independently designed and 
performed collaborative evaluations are funded. 
Collaborative clinical trials are the basis for 
developing standardized protocols in other forms 
of treatment and should be implemented as models 
for demonstration programs. Such a plan would 
allow effective programs or program components 
to be adequately described, replicated, and, if 
found useful, incorporated into certification 
standards. 

A services research issue worth noting here is the 
difficulties that drug treatment programs 
experience in securing zoning approval for clinical 
facilities, a problem usually summarized as "not in 
my back yard" (NIMBY). This problem, of 
course, is not confined to siting community drug 
treatment programs but confronts public utilities 
and services of many kinds. There is currently a 
NIDA-sponsored market research project 
(Technical Assistance & Training Corp., 1989) to 
create technical assistance materials to overcome 



this "barrier" to treatment. Research support for 
more definitive studies of program site effects—for 
example, on local real estate values and criminal 
victimization rates—would provide a better 
foundation for this work. 

Chemical Dependency 

Chemical dependency programs are the least well 
studied of the drug treatment modalities. The 
aggressive marketing deployed by many such 
programs has created suspicions about them in 
many quarters that cannot be allayed without 
investments in objective treatment research and 
evaluation. The optimal site of delivery and length 
of programming, including the duration of 
intensive treatment and aftercare periods, and the 
specific therapeutic elements necessary for an 
effective program should be investigated more 
closely. 

Only a few chemical dependency treatment 
providers have played positive roles in providing 
data and research opportunities for effectiveness 
studies. Many more need to do so to answer 
these questions: What is the effectiveness of 
chemical dependency treatment for drug- 
impaired clients of varying characteristics? Are 
there variations in program effectiveness—and if 
so, why? What are the actual costs and benefits 
of the most effective components of chemical 
dependency treatment? 

Cocaine Treatment 

The major efforts to date to investigate cocaine 
treatment efficacy occurred prior to the 
epidemiological reemergence of cocaine in the 
1980s. There is reason to believe that some 
findings about treatment modalities— such as the 
importance of time in treatment— will prove robust 
in the face of changing drug markets, but others 
may not. The infrastructure of treatment 
research centers decayed during the stagnation 
of drug research funding, and as this capability 
is rebuilt, it should specifically address the 
following questions about cocaine treatment: 
What are the most effective treatment elements 
for cocaine dependence and abuse? To what 



152 



NIDA DRUG SERVICES RESEARCH SERIES, No. 2 



degree can current modalities be effective for 
crack-cocaine? What new or existing 

pharmacological and nonpharmacological 
treatment elements can improve the clinical 
picture? 

Women, Children, and Adolescents 

The majority of individuals in treatment are adult 
males who are 20 to 40 years old, and their 
responses dominate treatment research statistics. 
The major findings of research to date on the 
effectiveness of different modalities and elements 
of treatment seem to apply roughly as well to 
adolescents and women with young children as 
they do to the more prevalent demographic groups 
(Hubbard et al., 1989). Yet the potential 
significance of child-bearing and child-rearing 
women and adolescent clients in terms of the 
future benefits of present treatment (or the future 
costs of present nontreatment) is great. Research 
plans in all areas need to devote special attention 
to differentiated knowledge about the two 
populations of adolescents and women with young 
children (including pregnant women). 

It seems clear from earlier studies that women in 
treatment who are pregnant or have young children 
are especially likely to bring particular needs to 
the treatment system (Beschner et al., 1981; Reed 
et al., 1982). For example, drug-abusing or 
dependent women on average have poorer self- 
esteem than men and suffer from greater anxiety, 
depression, and detachment; as a result, therapists 
who rely too heavily on confrontative techniques 
may worsen such problems rather than help reduce 
them. Because of their child care responsibilities, 
long-term residential treatment in TCs may be 
ruled out for many women unless there are special 
provisions for child care. In many states, long- 
term TC treatment becomes doubly problematic 
because extended residential treatment may 
jeopardize family eligibility for Aid to Families 
with Dependent Children (welfare) or threaten the 
mother's custody of the children. 

The federal block grant for alcohol, drug abuse, 
and mental health services mandates that 10 



THE EFFECTIVENESS OF TREATMENT 

percent of the grant be set aside to provide special 
services for women. According to the Institute of 
Medicine analysis of the 1987 National Drug and 
Alcohol Treatment Utilization Survey, about one- 
third of the more than 80,000 women in drug 
treatment were in programs that had at least some 
special services for women, although there is no 
further specification of the nature or extent of 
these services. Both clinical and services research 
are needed to gain an understanding of the nature 
and efficacy of current practices and the potential 
of innovations . 

The state of knowledge about adolescent treatment 
is, if anything, even less satisfactory. The number 
of useful studies of adolescents is small, and most 
work in this area is based too heavily on studies of 
treatment in much earlier periods (e.g., Friedman 
and colleagues [1986] analyze data on adolescents 
in the Drug Abuse Reporting Program of the early 
1970s). There are major obstacles to research on 
adolescents, including conceptual issues, such as 
discordant terminology for adolescent treatment 
service components, and logistical constraints, 
such as unmanageable requirements for obtaining 
parental consent. 

The committee recommends that a special study 
initiative be undertaken by the National 
Institute on Drug Abuse, in conjunction with 
other relevant agencies of the Public Health 
Service, on the treatment of drug abuse and 
dependence among adolescents and women who 
are pregnant or rearing young children. The 
initiative should review and summarize all 
available sources of evidence and insight from 
research and clinical experience, provide as much 
guidance as possible for current treatment efforts, 
and develop a comprehensive research agenda. 
The agenda in turn should be pursued by research 
agencies of the federal government and other 
sources of research support and carried forward by 
the community of clinicians and scientists. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



153 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER S 



CO 

z 
o 



260 

240 

220 

200 

180 

160 

140 

120 

100 

80 

60 

40 

20 






73 



75 



77 



79 



81 



83 



85 87 89 



FIGURE 5-8 Annual research obligations of the National Institute on Drug Abuse (in both nominal 
[current] and real [1989-equivalent] dollars) for fiscal years 1974-1990. 

Source: National Institute on Drug Abuse, unpublished data, 1989. 



754 



NIDA DRUG SERVICES RESEARCH SERIES. No. 2 



CHAPTER 6: TWO TIERS: PUBLIC AND PRIVATE SUPPLY 



To a person with a serious drug problem, or a 
referring clinician, or a parent looking for the best 
possible help for a troubled son or daughter, the 
paramount issues in drug treatment are simple and 
direct: what kind of treatment works best for this 
problem, and how easy is it to get access to the 
needed treatment in terms of quality, location, 
price, and openings? These individual concerns, 
repeated across hundreds of thousands of cases a 
year, cast a large question mark over the size, 
distribution, structure, and efficiency of the 
treatment supply system. 

For analysts, these questions are articulated 
somewhat differently. How well does the 
treatment supply system now meet the need for 
drug treatment? What general changes in scale or 
structure, if any, are necessary to improve the 
match between the supply of treatment and the 
need for it? What are the most important 
constraints or rigidities that condition the 
possibility of appropriate reforms? More 
concisely: Does the supply system match 
treatments to needs? If not, then why not, and 
how can it be fixed? 

In this chapter and the two chapters that follow, 
the committee attempts to resolve these issues. 
This chapter describes in qualitative and 
quantitative terms how the supply system is now 
constituted. This task was easier 10 to 15 years 
ago, for the system then was more uniform in its 
content, clients, and purposes and there was a 
national data collection system. Notwithstanding 
today's impoverished data, after thorough analysis 
the evidence clearly depicts the structure of the 
treatment system: there are two highly contrasting 
tiers of drug treatment—one for the poor under 
public sponsorship and one for those who can pay 
with private insurance or out-of-pocket funds. 

The existence of two tiers of providers is not 
unique in social and health services. Within the 



general medical delivery system there are public 
hospitals and clinics that primarily serve the poor 
and underinsured and private medical centers that 
primarily serve the affluent and well-insured. 

But the drug treatment system breaks that general 
mold in several critical respects. The two tiers of 
drug treatment differ from each other not only in 
their sources of financing but also in their recency 
and origins, provider and facility characteristics, 
modalities and services offered, clientele served, 
and capacity utilized (for example, the size of 
"waiting lists"). Moreover, the public tier 
interacts extensively with the criminal justice 
system. 

These contrasts are sharper and deeper than any of 
the differences that separate the two tracks of 
general medical care. Based on these differences 
and its previous analysis of treatment needs, the 
committee in this chapter reaches several general 
conclusions about the national supply system, 
including the relation of the public and private 
tiers, the nature of their major respective 
problems, and the general direction of needed 
reforms. Chapters 7 and 8 continue the discussion 
begun in this chapter but in greater depth. 



THE TWO TIERS: AN OVERVIEW 

It is useful to conceive of the treatment system as 
being made up of two tiers of providers. The 
public-tier providers are publicly owned programs 
or private, not-for-profit programs whose revenues 
are largely from government agencies. This tier 
includes large, multisite residential and methadone 
programs, but mostly it comprises small, not-for- 
profit outpatient clinics in about 2,000 
communities across the nation. These programs 
primarily serve clients who are indigent or 
underinsured. This system of care had its origins 
in the wars on crime and poverty of the late 1960s 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



1SS 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 6 



and early 1970s, and it was (and is) in many ways 
an adjunct to the criminal justice system. 

The private tier is made up of privately owned 
providers (both for-profit and not-for-profit 
programs) that serve clients who have private 
health insurance or sufficient financial resources to 
pay for drug treatment. The private tier has 
developed mainly from hospital units that 
originally focused almost entirely on medically 
directed inpatient treatment of alcoholism. Yet the 
characteristics of these programs are changing as 
outpatient care and aftercare become more 
important. This tier is growing rapidly, and the 
total revenues received by its providers are 
beginning to approach the total revenues of 
providers in the public tier. Within the private 
tier, the ranks of for-profit providers are growing 
more rapidly than the number of not-for-profit 
providers. 

There is very little overlap in providers and 
limited overlap of clientele between the two tiers. 
On the one hand, people with private health 
insurance rarely choose to be treated initially by 
programs that serve the indigent population. On 
the other hand, public subsidies often are not large 
enough to cover the charges of private-tier 
providers. There are a few programs—especially 
residential not-for-profit facilities—that straddle the 
two tiers, but they are dwarfed in number by those 
clearly belonging to one tier or the other. 



Financing Differences 

No data sources currently available permit a 
comprehensive description of the two tiers. 
Nevertheless, the tiers are sharply distinguishable 
in data collected in the 1987 National Drug and 
Alcohol Treatment Utilization Survey, or 
NDATUS. 1 The axis that most clearly divides the 
two tiers of treatment is source of revenue. 
Closely correlated with these tiers are radically 
higher levels of reimbursements for private clients, 
modest differences in the nature and richness of 
delivered care, and disparities in accessibility of 
services, with a much greater chance that 



applicants to the private tier can gain immediate 
admission to treatment. 

Figure 6-1 shows private revenues as a percentage 
of total revenues by type of treatment facility and 
ownership. The figure clearly shows that all types 
of for-profit providers serve primarily clients who 
are covered by private health insurance or who pay 
their own fees; these providers gain about 80 
percent of their revenues from these two courses. 
Government-owned providers clearly serve clients 
who are covered by government programs. Not- 
for-profit organizations are in the middle but are 
clearly differentiated by type of facility. More 
than 66 percent of the revenues of programs that 
are based in not-for-profit hospitals come from 
private sources. About 20 percent of the revenues 
of all other types of not-for-profit providers come 
from private sources; the remaining 80 percent of 
their revenues come from public contracts, grants, 
and reimbursements. 

Table 6-1 presents information, divided into the 
two tiers, on clients, facilities, and service 
intensity among the providers responding to the 

'The most recent editions of the survey, in 1982 (NIDA, 
1983a) and 1987, each came shortly after dramatic changes 
in the public financing system. First came the switch in FY 
1982 to federal block grants, the major effect of which was to 
reduce federal treatment funding virtually overnight by 25 
percent. The second major change was the 1986 Anti-Drug 
Abuse Act, which reversed the earlier trend and increased 
federal dollars for drug treatment by 20 percent. 

Several cautions are in order regarding the 1987 estimates. 
First, there is evidence from state reports (Butynski and 
Canova, 1988) that the response rate to the 1987 NDATUS 
may have been as low as 70 percent of all programs. Prior 
NDATUS efforts were reported to have had response rates of 
better than 95 percent. Second, financial data were omitted by 
almost 15 percent of responding programs. Thus, the 
estimates of treatment delivery and funding are conservative. 
(How conservative cannot be known unless nonresponse 
analysis is performed by the original survey contractor.) 
Moreover, this survey focused only on provider units 
specializing in drug and alcohol treatment. Probably not 
included in the NDATUS were such providers as community 
hospitals that deliver symptomatic treatment (detoxification) in 
scattered units and private practitioners-psychiatrists, 
psychologists, and social workers-who do not work in formally 
identified specialty service units. The 1987 data reported here 
are based on original analyses of the 1987 NDATUS data tape 
supplied to the committee by NIDA. 



756 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPLY 





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FIGURE 6-1 Defining the two tiers: private fees as a percentage of total revenues, by ownership and 
facility type. 

Source: Institute of Medicine analysis of tha 1987 National Drug and Alcoholism Treatment Utilization Survey. 

NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 1S7 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1. CHAPTER 6 



TABLE 6-1 Comparison of Selected Characteristics of the Public and Private Tiers of 
Drug Treatment 



Characteristic 



Annual admissions (in thousands) 
Current census (in thousands) 
Capacity (in thousands) 
Capacity utilization 
Additional capacity 

Revenues (millions of dollars) 
Revenue per admission 



Total 



Private 



Public 



848 


212.4 


636.0 


263 


47.5 


215.9 


329 


72.2 


256.5 


80% 


66% 


84% 


25% 


52% 


19% 


1,312 


521 


791 


1,550 


2,450 


1,240 



Facilities 



Hospitals 

Residential 

Outpatient 

Methadone 

Corrections 



5,121 



1,275 



3,846 



960 


801 


159 


990 


76 


914 


2,765 


331 


2,434 


334 


67 


267 


72 





72 



Clients per counselor 

Inpatient 
Outpatient 

Outpatient appointments/week 



9.1 
38.5 

1.7 



7.2 
37.3 

1.9 



9.7 
38.8 

1.65 



Source: Institute of Medicine analysis of the 1987 National Drug and Alcoholism Treatment Utilization Survey. Data were provided by 
the National Institute on Drug Abuse. 



158 



NIDA ABUSE SERVICES RESEARCH SERIES. No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPLY 



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FIGURE 6-2 Two tiers of cost: estimated revenues per client in each tier, by facility and tier. 

Source: Institute of Medicine analysis of the 1987 National Drug and Alcoholism Treatment Utilization Survey. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



159 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1. CHAPTER 6 



LU 

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FIGURE 6-3 Additional available treatment capacity in the national drug treatment system by facility 
type, as a percentage above current client census. 

Source: Institute of Medicine enalyaia of the 1987 National Drug and Alcoholism Treatment Utilization Survey. 



160 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPLY 



NDATUS in 1987. The private tier comprises all 
for-profit providers plus private not-for-profit 
hospitals; the public tier comprises all other not- 
for-profit facilities plus government-owned 
programs. Private-tier providers received 

41 percent of the reported drug treatment 
expenditures while treating 22 percent of the 
clients; public-tier providers received 59 percent of 
total revenues and treated 78 percent of the clients. 
The average revenue per client admitted to a 
private-tier program was $2,450, compared with 
$1,240 per public-tier admission. The primary 
factor in this difference in revenues is the locus of 
services offered in the two sectors. About 83 
percent of the revenues received by the private tier 
were generated by hospital-based programs, in 
contrast to 9 percent in the public tier. Moreover, 
inpatient and residential revenues per client in 
private-tier facilities were three to four times 
greater in private- than in public-tier facilities, 
although average outpatient revenues per client 
were nearly identical (Figure 6-2). 

The programs of private-tier providers were more 
service intensive than those of public-tier 
providers. In the private residential and inpatient 
setting, there were 7.2 clients per counselor, 
compared with 9.7 clients per counselor in the 
public setting. Although the number of clients per 
counselor in the outpatient setting was more nearly 
similar for both tiers, private-tier clients were seen 
more often. However, without adjusting for group 
versus individual therapy and for the size of the 
groups, data not available from the NDATUS, 
these findings concerning personnel ratios must be 
viewed cautiously. Finally, although much more 
expensive, the duration of treatment tends to be 
somewhat shorter in private- than in public-tier 
facilities. The net impact of these differences vis- 
a-vis quality of care is difficult to assess because 
the two systems serve quite different types of 
clients, and those differences probably extend to 
client therapeutic needs. 

Client Differences 

Compared with private-tier clients, public clients 
have longer histories of drug taking, are more 



likely to have taken more types of drugs, are less 
likely to be employed or engaged in other socially 
conventional activities, are more likely to have 
major social deficits (e.g., education), and are 
more likely to have records of criminal activity 
and involvement with the criminal justice system. 
These differences are evident in all of the major 
studies of public-tier clients, including the Drug 
Abuse Reporting Program, or DARP (Sells, 
1974a,b); CODAP, the Client-Oriented Data 
Acquisition Process; and TOPS, the Treatment 
Outcome Prospective Study (Hubbard et al., 
1989), when contrasted with multiprogram studies 
of private-tier clients (e.g., the Chemical 
Abuse/ Addiction Treatment Outcome Registry, or 
CATOR, as reported in Hoffmann and Harrison 
[1988] and Comprehensive Care Corporation 
[1988]). 

Most of the clients served in the public tier have 
many deficits such as diminished general health, 
poor education, and family breakdown. These 
deficits may be due to their drug problems, or they 
may predate such problems and exacerbate them. 
Public-tier providers thus need to have a variety of 
services at hand to accomplish their therapeutic 
goals. As a consequence, their staff requirements 
may well be higher than those of private-tier 
providers, and the staff patterns shown in Table 6- 
1 probably mask deep-seated differences in the 
program resources available to achieve their 
therapeutic objectives. 



Capacity Differences 

In 1987 there was considerable excess capacity in 
the nation's drug treatment system. (The extent of 
capacity utilization in the two tiers is shown in 
Table 6-1 and Figure 6-3.) Capacity utilization 
varies by type of program and by tier. In general, 
there is considerable excess capacity throughout 
the private tier and much less in the public tier. 
There is excess capacity in hospital-based 
programs but little excess capacity in methadone 
programs. Nationwide, public methadone 

programs reported about 5 percent excess capacity- 
-quite a narrow margin as these programs often 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



161 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 6 



have unexpected dropouts and chronic staff 
shortages. The excess capacity is not evenly 
distributed across the country. Programs in cities 
and states are virtually full, with long waiting lists. 
Moreover, excess capacity, particularly in the 
private tier, does not necessarily mean that there is 
currently idle or underused staff and space. 
Rather, it indicates providers' willingness to 
expand and accept additional clients and to 
increase staffing and other program inputs 
appropriately. 



THE GROWTH OF THE NATIONAL 
TREATMENT SYSTEM 

Trends in Client Numbers and 
Provider Characteristics 

The characteristics of the national treatment system 
have changed over time. Most of the data comes 
from the NDATUS series, which has been 
conducted by the National Institute on Drug Abuse 
(NIDA) since 1976. The basic trends are shown 
in Figure 6-4. 

In 1976 there were approximately 229,000 
individuals in treatment on a daily basis. The 
majority were in outpatient nonmethadone 
programs. The next largest group was in 
methadone maintenance, followed respectively by 
residential and hospital programs. Enrollment in 
the residential and outpatient nonmethadone 
modalities declined steadily from 1976 through 
1982, although in some areas of the country, 
residential treatment enrollment was stable even in 
the face of dwindling funds. In the subsequent 
five years, however, residential and outpatient 
nonmethadone enrollment rebounded dramatically; 
in contrast, methadone maintenance enrollment 
remained fairly stable. The methadone census 
peaked at 80,000 in 1977, declined to 68,000 in 
1980, and increased to 72,000 in 1982 and to 
82,000 in 1987. 

In light of the great national concern about drugs 
and crime, it is surprising to observe that formal 
drug treatment in correctional settings canvassed 



by the NDATUS fell steadily from 9,100 clients in 
1977 to 6,200 in 1982. This figure was nearly 
unchanged in 1987, even though the number of 
inmates had more than doubled during the five- 
year period. A Bureau of Justice Statistics survey 
(Innes, 1988) estimated that more than 30,000 state 
prison inmates were receiving drug treatment in 
1986, many of them evidently in programs not 
recognized and included in the 1987 NDATUS. It 
is likely that these additional inmates were 
reporting on drug-specific problems discussed 
during the course of general prison counseling, 
education, or medical services. 

The most radical changes were in the hospital 
census, which declined from 5,500 in 1976 to 
below 3,000 during 1978-1982 and then rebounded 
to 10,600 in 1987. When the drug treatment 
system was built up in the early and mid-1970s, 
hospital-based care was judged to be no more 
effective in most cases than residential care (or, 
for many clients, than outpatient care) in 
protecting health or promoting recovery, but 
hospitals were clearly much more expensive 
(Stategy Council on Drug Abuse, 1975; Besteman, 
1992). Therefore, the use of federal drug 
treatment funds was restricted to medically 
complicated detoxification; they could not be used 
for any hospital-based rehabilitation treatment. By 
October 1987, however, total enrollment in 
hospital-based detoxification still was only 3,369 
clients, but hospital-based inpatient rehabilitation 
treatment had grown exponentially and was being 
delivered every day to 7,279 patients. 

The parallel trend is in the number of hospitals 
newly reporting specialty treatment units for drug 
problems. This type of facility increased from 350 
in 1982 to 960 in 1987 and reported a total of 
180,000 admissions of individuals for drug 
problems (21 percent of total 1987 admissions). 
Five out of six of these hospitals were in the 
private tier. 

Another recent trend is away from programs that 
mainly treat drug problems and toward units that 
treat both alcohol and drug problems. Prior to 
1982 the majority of drug treatment programs 



162 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPLY 



CO 
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120 

110 

100 

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80 

70 

60 

50 

40 

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/ 



/ 



y 



s 



Residential 



81 




FIGURE 6-4 Drug treatment client census by treatment modality, 1976-1987. 

Sources: National Institute on Drug Abuse (1 976-1 980, 1 983a); Institute of Medicine analysis of the 1 987 National Drug and Alcoholism 
Treatment Utilization Survey. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 6 



1400 r 



v. 

o 



W 
C 
.2 

I 

c 

O 

Z 

Q 

Z 
=) 
Li- 



Nominal Funding 




1,310 



520 



FIGURE 6-5 Drug treatment system funding for 1976-1987 in nominal and real 1976 dollars. 

Sources: National Institute on Drug Abuse (1 976-1 980, 1 983a); Institute of Medicine analysis of the 1 987 National Drug and Alcoholism 
Treatment Utilization Survey. 



164 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPLY 



treated drug clients only. This situation has now 
changed dramatically. The vast majority of 
programs (80 percent) now treat both drug and 
alcohol problems. Since the first survey to make 
the distinction, the 1979 NDATUS, specialty units 
treating only drug problems have decreased in 
number from 2,000 to 1,000. 

A last major change is in the balance of ownership 
of programs. The number of government-owned 
programs has changed little, going from 950 in 
1982 to 1,020 in 1987). But private for-profit 
programs multiplied from 159 units with 9,800 
clients (daily count) to 730 units with 29,000 
clients. Private not-for-profit units grew from 
1,900 to 3,400 programs, with an almost 
proportionate increase in clientele. Thus, drug 
treatment facility growth has been largely in the 
private tier, especially among hospital-based 
combined drug and alcohol (chemical dependency) 
units. 

In 1987 most of the programs (2,750) in the drug 
treatment system offered outpatient nonmethadone 
treatment as their primary modality. Nearly 1,000 
hospitals, another 1,000 residential (nonhospital) 
programs, 330 methadone maintenance outpatient 
programs, and 72 correctional facilities with 
specialty drug treatment programs completed the 
drug abuse treatment system. The total enrollment 
of 263 ,000 persons in 1987 was 50 percent greater 
than in 1982, although only 20 percent larger than 
in 1976, the first year of the NDATUS. About 
848,000 persons were admitted to drug abuse 
treatment in NDATUS programs during the 12 
months preceding the census date, October 31, 
1987. A total of 263,000 persons were currently 
enrolled in drug treatment as of October of that 
year. Treatment was provided by 5,100 different 
specially facilities at an annual cost of $1 .3 billion. 
Additional health care was undoubtedly provided 
by general health care providers (hospitals with no 
specialty units, physicians in their offices), but this 
care was presumably symptomatic in nature 
(treatment of emergency overdoses, accidents, or 
infections) and did not constitute efforts to 
rehabilitate drug abuse or dependence as such. 



The vast majority (225,000, or 86 percent) of 
clients in drug treatment during October 1987 were 
being treated on an ambulatory basis— either 
methadone maintenance or outpatient 
nonmethadone treatment— although previously they 
may have received inpatient or residential services. 
The backbone of the public drug treatment system 
was 3,100 primary ambulatory programs that 
admitted 506,000 clients in 1987 and had 194,000 
clients as their static population number (including 
a small number temporarily in hospital and 
residential beds). The 1,950 hospital and 
residentially based programs in the system 
admitted 303,000 clients during 1987 and had a 
static enrollment of 62,000 clients; however, 50 
percent of these clients were enrolled in their 
outpatient (including aftercare) services. 
Nonhospital residential facilities served 27,000 
persons and hospital inpatient wards, 10,600 
persons. Hospital and residential revenues, 
however, were substantially greater than 
ambulatory and outpatient receipts. 

There were more clients in drug treatment in 
October 1987 than at any previously recorded 
date. The 5,100 programs reporting to the 
NDATUS for 1987 were the largest number ever 
recorded, up from only 3,000 in 1982. 



Trends in the Funding Base 



The specialty drug treatment sector had revenues 
of $1.3 billion in 1987 (based on the NDATUS), 
which is sharply above the total system funding of 
$530 million in 1982 and $500 million to $600 
million per year in the 1976-1980 period (Figure 
6-5). Yet in terms of real dollars or purchasing 
power, funding of the national treatment system 
has seriously deteriorated since the first NDATUS. 
Adjusting for inflation by using the medical price 
index, total 1976 funding was worth 15 percent 
more than total 1 987 funding (Figure 6-5) . On a 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 6 



per-client basis the real value of funding decreased 
about 21 percent from 1976 to 1987. 2 

The erosion in funding is further indicated in data 
on funding per client in single-modality treatment 
programs from 1976 through 1987 (Figure 6-6). 
Although the nominal dollar values indicate 
growing revenue per client over the period, in real 
terms there was a decrease. The outpatient 
nonmethadone and the methadone maintenance 
revenues per client declined by about one-third. 
The decrease in real expenditures, however, does 
not necessarily extend to the private tier. In the 
one meaningful series in which a comparison of 
modalities in each tier across time is possible, 
residential treatment per client in the public tier 
was funded in 1987 at 15 percent below the 1976 
level after adjusting for inflation, whereas the 
private-tier equivalent was about 150 percent 
higher. 



Sources of Treatment Dollars 

Underlying the shifts in clients and providers were 
substantial changes in who paid for treatment 
(Table 6-2). In 1976 the federal government paid 
for at least 43 percent of drug treatment (NIDA, 
1978), and state and local governments paid for 48 
percent. The rest of the funds came from private 
fees and donations. Since that time, private 
payments for drug treatment services have 
increased dramatically and represent the most 
fundamental financial change in the system, largely 
corresponding to the increasing treatment of drug 



'inflation adjustment might be performed with the consumer 
price index (CPI) rather than the medical price index (MPI), but 
the latter is more realistic because treatment system personnel 
are hired in the medical labor market. In 1982 the NDA TUS 
(NIDA, 1983a) found that drug program staffs were composed 
of physicians (3 percent), clinical psychologists (5 percent), 
social workers (7 percent), nurses (9 percent), counselors (35 
percent), other medical and direct care personnel (17 percent), 
and medical administrators and support staff (24 percent). 
When the CPI is used for inflation adjustment, real system 
revenues are 9 percent higher in 1987 than in 1976, and funds 
per client year are nearly identical. 



problems in private hospital facilities. Even within 
governmental funding, there has been a distinct 
trend away from grant funding and toward more 
use of fee-for-service reimbursements. 

In 1987, contracts and vendor reimbursements 
from states and local governments ($483 million) 
were the most important sources of revenue for 
drug treatment providers. These monies, however, 
incorporated federal block grant funds 
administered by the states. Block grant outlays in 
FY 1987 are estimated to have been about $110 
million, or half of the $220 million available for 
alcohol and drug treatment (Butynski and Canova, 
1988) after the 20 percent set-aside for prevention. 
State and local governments thus spent about $373 
million of their own appropriations for drug 
treatment, compared with $110 million in federal 
block grant monies. Programs reported the receipt 
of another $47 million in federal categorical 
contracts, $139 million from Medicaid, Medicare, 
or other public insurance, and $56 million for 
welfare and social service payments (e.g., housing 
and food allowances for clients in residential 
environments). The exact federal share of these 
later payments is uncertain, but it is assumed to be 
about 50 percent because the federal contribution 
to Medicaid is a minimum of 50 percent. 
Medicare (which is all federal dollars) has 
historically experienced a small number of claims 
for drug treatment. 

In sum, state and local government expenditures 
on drug treatment from all sources were 
approximately $470 million, or 37 percent of total 
NDATUS expenditures, and the federal 
contribution was about $250 million, or 19.5 
percent of the total (Figures 6-7a and 6-7b). 
About 36 percent of government treatment 
expenditures in 1987 (up from 16 percent in 1979) 
came from public insurance payments (primarily 
Medicaid), welfare/social services payments, and 
local/state government fee-for-service 
reimbursements. Nongovernmental revenue 

constituted a large share of total system funding in 
1987. With $348 million from private insurance 
and $157 million from client out-of-pocket 



166 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPLY 



00 
TJ 

C 
CO 
CO 

3 

o 

SZ 



CC 
< 

LLI 

> 



LU 



UJ 
Q. 

C/D 

CC 

< 

-J 
—I 

o 

Q 



4.0 r 
3.8 
3.6 
3.4 

3.2 
3.0 
2.8 
2.6 
2.4 




76 



78 



,630 ^~--^^^ 



2,540 
■^^.^2,390 



_L 



80 82 

YEAR 



84 



86 



FIGURE 6-6 Annual funding per client year in methadone and outpatient nonmethadone programs 
during 1976-1987 (in 1987 dollars). 

Sources: National Institute on Drug Abuse (1 976-1 980, 1 983a); Institute of Medicine analysis of the 1 987 National Drug and Alcoholism 
Treatment Utilization Survey. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



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SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1. CHAPTER 6 



TABLE 6-2 Funding of the National Treatment System, 1 976-1 987, by Year and Final 
Source of Funding (in millions of dollars) 



Source 


1976 


1977 


1978 


1979 


1980 


1982 


1987 


NIDA/ADAMHA" 


160.8 


119.3 


131.6 


143.7 


127.6 


79.4 


11.2 


Other federal agencies 


88.3 


50.0 


47.4 


48.5 


44.8 


46.1 


36.3 


State" 


206.0 


177.3 


164.5 


147.7 


133.8 


165.4 


355.3 


Local 


77.5 


51.2 


58.1 


43.5 


39.9 


41.4 


64.1 


State/local fee-for- 
















service reimbursements 


0.0 C 


0.0 


0.0 


3.2 


10.7 


16.6 


74.3 


Welfare/social services 


0.0 


0.0 


25.9 


21.6 


20.2 


22.4 


55.8 


Public third party 


0.0 


0.0 


0.0 


49.5 


44.5 


62.2 


139.5 


Private third party 


0.0 


0.0 


0.0 


11.2 


20.0 


43.5 


348.1 


Client fees 


0.0 


0.0 


17.6 


17.2 


21.3 


35.6 


157.3 


Other 


70.8 


112.9 


73.0 


24.6 


23.8 


21.1 


69.8 


Total 


603.4 


510.7 


518.1 


510.7 


486.6 


533.7 


1,311.7 


Total (in 1987 $} 


1,519.1 


1,173.3 


1,098.1 


990.7 


851.0 


755.0 


1,311.7 



Revenue per client 
in treatment 2,500 2,200 2,400 2,500 2,700 3,100 5,000 

Revenue (in 1987 $) 
per client in treatment 6,300 5,000 5,100 4,900 4,700 4,400 5,000 



"National Institute on Drug Abuse/Alcohol, Drug Abuse, and Mental Health Administration. 
"Incorporating federal disbursements (e.g., block grant funds) administered by state authorities. 
c From 1976-1978, cells reported as "0.0" were included in the "Other" category. 

Source: For 1976-1980, data were taken from the National Institute on Drug Abuse reports of data from the National Drug and 
Alcoholism Treatment Utilization Survey (National Institute on Drug Abuse, 1 976-1 980). For 1 982 data, see National Institute on Drug 
Abuse (1983a). The figures for 1987 were derived from the Institute of Medicine analysis of the 1987 National Drug and Alcoholism 
Treatment Utilization Survey. 



765 NIDA ABUSE SERVICES RESEARCH SERIES. No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPLY 



a Other (4.3%) 

197© Private (5.0%)^ 




Federal (42.5%) 



State & Local (48.2%) 



b 

1987 



Other (5.3%) 



Private (38.5%) 




Federal (19.5%) 



State & Local (36.7%) 



FIGURE 6-7 (a) Funding sources for drug treatment in 1976 (total expenditures: $603 million). 

Source: National Institute on Drug Abuse (1976-1980). (b) Funding sources for drug treatment in 1987 (total expenditures: $1,311 
billion). Source: Institute of Medicine analysis of the 1987 National Drug and Alcoholism Treatment Utilization Survey. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



169 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 6 



payments, private reimbursements totaled $505 
million, or 38.5 percent of all revenues. 



Trends in Federal Funding 

Federal funding has played a major role in shaping 
the drug treatment system. Nominal federal 
funding grew from $40 million in FY 1969 to a 
peak of $300 million in FY 1974; it stabilized at 
$250 million to $290 million between 1975 and 
1980, then rapidly declined to $160 million in 
1982 before again growing to $190 million in 1986 
and doubling to $370 million in 1987 and 1988 
(Figure 6-8). Final figures for 1989 and tentative 
figures for 1990 are not yet certain, but they are 
likely to be comparable to those of the late 1970s. 
These shifts up and down are even more dramatic 
after adjusting for inflation. 

Federal treatment monies directed toward 
community-based treatment come primarily from 
Alcohol, Drug Abuse, and Mental Health 
Administration (ADAMHA) categorical and block 
grant funds (Table 6-3). These figures also 
demonstrate the magnitude of fluctuations in 
federal funding for publicly provided treatment 
between 1980 and 1990. 

It is important to consider the role of treatment in 
the federal anti-drug abuse strategy. From 1969 to 
1975, the federal government put more of its anti- 
drug abuse resources into treatment than into 
criminal justice or prevention activities. That 
pattern has now changed. In 1989 criminal justice 
efforts received an estimated $2.6 billion, 
compared with $680 million for prevention and 
$520 million for treatment (Figure 6-9 and Table 
6-4). 

In summary, the nation's drug treatment system 
began to erode after 1976. Although the private 
tier grew steadily all through the 1980s and the 
public tier has been increasing since the middle of 
that decade, the drug treatment system is still 
notably weaker and smaller than it was in 1976 in 
aggregate funds and in resources per client served. 
Sources of overall support for the treatment system 



have changed materially. The governmental share- 
-particularly that of the federal government—has 
declined, whereas private reimbursements have 
been growing. Even with the recent large 
increases in funding through the Anti-Drug Abuse 
Acts of 1986 and 1988 and the emergency 
ADAMHA appropriation for FY 1990, federal 
support for treatment in inflation-adjusted dollars 
is still well below the level achieved in 1973-1974. 



CONCLUSION 

The most important feature of the nation's drug 
treatment supply system is its very clear division 
between two tiers of providers that differ in 
financing, origins, clientele, capacity utilization, 
and modalities. There is a public tier of mostly 
outpatient and residential programs for indigent 
clients, many with serious criminal records and 
other social deficits, that is about 20 years old; and 
there is a smaller private tier of mostly hospital- 
based programs for middle- and upper-class 
clients, which is effectively about 10 years old. 

The 1987 NDATUS, although a limited and 
imperfect instrument of observation, gives the 
clearest available picture of the two tiers. Its data 
show a private tier composed of 1,275 treatment 
providers, all of whom were receiving at least half 
(on average, more than three-quarters) of their 
revenues from client fees or private third-party 
reimbursements. More than 800, or 63 percent, of 
these private-tier providers were in-hospital 
programs (both for profit and not for profit); about 
25 percent (334) were outpatient programs; and the 
remaining 11 percent were about evenly divided 
between residential and methadone programs. 

The public tier revealed by the 1987 NDATUS 
comprised 3,846 providers receiving on average 
just below one-fifth of their revenues from client 
fees or private reimbursements. More than 2,400 
(63 percent) of these programs were outpatient 
facilities (largely private, not-for-profit 
contractors); 24 percent (914) were residential 
facilities; and the remaining 13 percent were 
divided among methadone programs (267), 



770 



NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPL Y 



government hospitals (159), and correctional 
programs (72). 

The private tier treated 22 percent of all reported 
admissions and received 41 percent of system 
revenues; it averaged $2,450 per treated client, 
double the $1,240 average in the public tier. This 
cost difference was largely attributable to two 
factors. Most private-tier (but relatively little 
public-tier) treatment takes place in hospitals, 
which are more expensive than other settings; 
moreover, the average per diem charge in private- 
tier hospital programs is about four times as high 
as the average charge in public-tier hospital 
programs. There is also a threefold average 
differential between the costs of private and public 
nonhospital residential programs. Only the 
outpatient (methadone and nonmethadone) 
programs were similar in cost in the two tiers. 

The level of per diem support per client in the 
public tier fell substantially from the mid-1970s to 
the mid-1980s, although there has been a notable 
recovery in the past three years. The actual cost 
of delivering treatment has not declined; rather, 
the intensity and breadth of program services and 
the experience levels of public-tier staff have been 
reduced. The public tier was originally built, 
staffed, and trained in the early 1970s largely with 
federal dollars, under an explicit plan to steadily 
reduce the federal contribution and increase state 
and local dollars in proportion. Something like 
this has occurred, but the federal decline has been 
much more pronounced than the state and local 
increases. This pattern is attributable to a general 
shrinkage in public services and a more specific 
shift back toward the criminal approach to drug 
problems, rather than to patterns or trends in the 
severity of the drug problem— the epidemiological 
trends in dependence during the early part of this 
period were stable and in the latter part have been 
rising. 

Private drug treatment was a small, nearly 
invisible presence throughout the 1970s but then 
began exponential growth after 1980. This growth 
largely involved increasing delivery of drug 
treatment in preexisting or newly opening 



alcoholism treatment units, which began to see 
increasing numbers of alcohol/drug and drug-only 
(mostly marijuana and cocaine) clients among their 
insured clientele; some programs also began 
aggressive efforts to reach more such patients as 
the incidence of alcoholism stopped growing 
during the 1980s. The extension of alcoholism 
treatment capacity to drug treatment occurred in 
the public tier as well and is manifest in the sizable 
increase in the self-designation of NDATUS 
treatment units as combined alcohol/drug 
providers. There was also a large expansion of 
private methadone programs as political opposition 
to methadone maintenance combined with 
budgetary pressures to close down existing public 
methadone clinics. 

How well does the treatment system match current 
demand and the estimated need for services? In 
the 1987 NDATUS, reports of additional treatment 
capacity (which the committee has interpreted to 
mean idle capital assets, adequate licensing and use 
permits, and access to additional personnel 
comparable in training to those already employed) 
was highest (more than 50 percent above the 
current census) in private and public hospitals and 
in private-tier residential facilities; it was lowest in 
public-tier methadone and outpatient facilities. 
There were substantial regional differences in 
public-tier capacity; consequently, some areas of 
the country are sorely pressed for public-tier 
residential treatment as well. 

The two tiers are so differently configured that it 
is not sensible, in the committee's judgment, to try 
to engage more private-tier capacity on a large 
scale for public use. There is a need for 
expansion of the public tier— but with an important 
reservation. The current resource intensity of 
many public-tier programs is marginal at best. 
Expansion will reduce and dilute this intensity 
unless careful countermeasures are taken. The 
need for more resource-intensive treatment appears 
at least equal in importance to increases in 
capacity. Rigorous data on the clinical 

effectiveness of more intensive resources per 
patient are too sparse to permit certainty or 
precision on this point, but the most sensible 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



171 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 6 

course, in the committee's judgment, is to divide 
increased public resources between improving the 
quality of services, facilities, and staff skills and 
increasing the capacity for new admissions. A 
high priority should also be assigned to creating 
data resources and analyses that will permit a close 
look at the relation of service intensity, quality, 
and treatment outcomes. 

Although the rise in severe cocaine problems has 
meant reductions in opiate drug use in some areas, 
overall this trend has added to rather than undercut 
other drug problems such as heroin dependence. 
Because methadone maintenance—provided at 
adequate levels and with supporting services—is the 
most rigorously validated treatment for heroin 
dependence, there is good reason to put additional 
resources into this modality in areas of the country 
where need and demand for it are strongest, 
keeping in mind the general principle of improving 
treatment resource intensity in parallel with 
capacity. The private tier may be capable of 
offering methadone treatment as efficiently as the 
public tier, although the scarcity of evaluation 
research on private-tier methadone treatment 
warrants serious caution. 



172 NIDA ABUSE SERVICES RESEARCH SERIES, No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPL Y 



1400 r 




88 89 



FIGURE 6-8 Federal drug treatment expenditures during FY 1969-1989 (in nominal and real 1969 

dollars). Source: Strategy Council on Drug Abuse (1975 end leter years); White House Office of Public Affairs (1988); Office of 
National Drug Control Policy (1989). Price deflators were provided by the Bureau of Labor Statistics. 



DC 

_J 

o 

Q 

r*. 
oo 



z 
O 



CO 




69 71 73 



75 77 79 81 83 85 
YEAR 



87 89 



FIGURE 6-9 Federal anti-drug abuse funding for FY 1969-1989 (in 1987 dollars), sources: Nominal drug 

expenditure data from the Strategy Council on Drug Abuse (1975 and later years); White House Office of Public Affairs (1988); Office 
of National Drug Control Policy (1989). Price deflators were provided by the Bureau of Labor Statistics. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



173 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1. CHAPTER 6 



TABLE 6-3 Federal Appropriations (in millions of dollars) for Drug, Alcohol, and 
Mental Health Treatment Provided Through Alcohol, Drug Abuse, and Mental Health 
Administration (ADAMHA)-Administered Categorical and Block Grants, 1980-1989 









Estimated Portion 




ADMS 8 


ADTR 


for Drug 


Year 


Block Grant 


Supplement 6 


Treatment 


1980 


625 d 


.. 


256 


1981 


543 


-- 


136 


1982 


428 


- 


107 


1983 


468 


- 


117 


1984 


462 


- 


92 


1985 


490 


-- 


98 


1986 


468 


- 


93 


1987 


508 


163 


167 


1988 


487 


156 


160 


1989 (est.) 


765' 


~ 


260 


1990 (tent.) 


1,133' 


"" 


448 



"Alcohol, drug, and mental health services (ADMS). 

"Alcohol and drug treatment (ADTR) supplemental 1987-1988 appropriations. 

""Approximately half of the ADMS block grant was for drug and alcohol treatment. All of the ADTR monies 

were for drug and alcohol treatment. Congress instituted a 20 percent set-aside of the block grant funds 

for prevention services in 1 984. Approximately half of the block grant substance abuse treatment funds 

have been spent on drug treatment. Statutorily, not less than 35 percent of the substance abuse monies 

could be spent on either drug or alcohol treatment. 

d ln 1980 this figure was an aggregate of categorical grant programs for alcohol, drug, and mental health 

services. In later years these funds were collapsed into the ADMS block grant. 

'The 1989 appropriation of $805.6 million was effectively reduced to $765 million by a 10 percent set-aside 

for data collection, technical assistance, and services research. 

'Adding the 1990 tentative set-aside of 5 percent yields the actual block grant total ($1,192 billion). 

Source: Unpublished data from the ADAMHA Office for Treatment Improvement. 



774 NIDA ABUSE SERVICES RESEARCH SERIES. No. 2 



TWO TIERS-PUBLIC AND PRIVATE SUPPL Y 



TABLE 6-4 Federal Anti-Drug Abuse Expenditures (in millions of dollars) for 
Treatment, Prevention, and Criminal Justice: Obligations for Fiscal Years 1969-1989 
Provided in Nominal and Inflation-Adjusted Figures 





Nominal Dollars" 




Real 1987 Dollars 6 










Criminal 
Justice 






Criminal 


Year 


Treatment 


Prevention 


Treatment 


Prevention 


Justice 


1969 


40 


10 


40 


160 


20 


120 


1970 


50 


20 


60 


190 


70 


180 


1971 


80 


50 


90 


290 


130 


260 


1972 


170 


110 


170 


600 


310 


460 


1973 


280 


140 


210 


950 


350 


540 


1974 


310 


160 


280 


960 


360 


640 


1975 


250 


110 


320 


700 


230 


660 


1976 


250 


110 


360 


620 


210 


700 


1977 


260 


110 


370 


590 


200 


670 


1978 


260 


110 


420 


560 


190 


720 


1979 


290 


120 


470 


560 


190 


730 


1980 


270 


140 


550 


480 


190 


770 


1981 


210 


120 


810 


330 


150 


1,030 


1982 


160 


120 


980 


230 


150 


1,180 


1983 


180 


140 


1,190 


240 


160 


1,370 


1984 


180 


150 


1,420 


230 


170 


1,560 


1985 


190 


180 


1,670 


220 


190 


1,780 


1986 


190 


190 


1,760 


200 


190 


1,830 


1987 


370 


320 


2,290 


370 


320 


2,290 


1988 


370 


450 


2,490 


340 


440 


2,400 


1989 


520 


680 


2,660 


450 


630 


2,460 



"Nominal drug expenditure data are taken from Strategy Council on Drug Abuse (1 975 and later years), White 
House Office of Public Affairs (1988), and Office of National Drug Control Policy (1989). 
b Price deflators were provided by the Bureau of Labor Statistics. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



175 



CHAPTER 7: PUBLIC COVERAGE 



The question of whether there should be a large- 
scale system of publicly supported drug treatment 
was answered affirmatively in the 1970s. That 
answer has been reaffirmed in the past few years, 
and the committee's analysis to this point has not 
raised any fundamental new doubts. With the 
existence and legitimacy of the public tier no 
longer at issue, the questions for public coverage 
are instead ones of management objectives and 
techniques. The task of this chapter is to consider 
the present system of public coverage in light of 
the needs, wants, and demands placed on it and to 
make appropriate recommendations for 
improvement. 

First, it is necessary to frame the fundamental 
policy questions that those responsible for public 
coverage of drug treatment should address—a 
critically important endeavor. Even when some of 
the answers can only be provisional, approximate, 
or resolvable by public debate and political 
negotiation, asking the right questions is essential 
in order to assemble relevant evidence and give 
rational shape to the decision-making process. 

Policy has to do with ends and means. The 
committee sees three questions under each of these 
categories. In deciding on the ends of treatment 
policy, the questions are as follows: 



■ What are the fundamental principles that justify 
public coverage of drug treatment? Or, whose 
treatment should public funds cover, and why? 

■ What priorities should guide the current 
expansion of public coverage? 

■ What is the optimal level of public spending to 
implement these priorities? 

The committee identifies as principles that public 
coverage should seek to remedy treatment 



constraints that arise from inadequate income and 
to reduce external social costs, particularly those 
relating to crime and family role dysfunctions. 
Such efforts often require actively inducing people 
to seek treatment through a variety of methods, as 
well as seeking mechanisms to increase retention 
(e.g., legal coercion, outreach efforts, enhanced 
social services) . Four specific priorities flow from 
these principles and conform to the committee's 
empirical analysis: reduce admission delays, 
improve program quality and performance, reach 
out to young mothers, and treat more criminal 
justice clients. This chapter outlines three 
progressive strategy options for public decision 
makers to consider: a core spending strategy, an 
intermediate plan, and a comprehensive option. 

The priorities and expenditure patterns 
recommended in this chapter should not be 
implemented without reconsidering the adequacy of 
present means for managing the public tier. These 
considerations divide into three instrumental 
questions: 

■ What should be the respective state and federal 
roles in public coverage of drug treatment? 

■ What are the most appropriate financial 
mechanisms for providing public support- 
essentially, to what degree should the 
emphasis be on direct service programs versus 
public insurance? 

■ What disciplines or controls should be in place 
to ensure that public expenditures for drug 
treatment are appropriate and effective? 

State governments have played the major role in 
financial administration and quality control of drug 
treatment in recent years. Now, however, the 
federal government, in pumping major new funds 
into treatment, is reasserting its earlier leading 
role. It should take this opportunity to rebuild 



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important directional and accountability 
mechanisms and to prepare the ground for later 
introduction of a larger share of public insurance 
financing. (However, public insurance financing 
will never obviate the need for direct service 
support of critical program elements such as 
outreach and integration with nonhealth services.) 
Routine outcome measurement, training and 
technical assistance, gatekeeping functions, and 
performance contracting will be the keys to 
upgrading drug treatment and introducing it 
permanently into the mainstreams of health and 
human services. 



THE PRINCIPLES OF 
PUBLIC INTERVENTION 

Twenty-five years ago, publicly supported drug 
treatment in the United States was confined to the 
provision of certain therapeutic amenities at four 
correctional facilities. Each site admitted hundreds 
of drug-abusing and dependent individuals in a 
given year; most of them were convicted of 
narcotics violations, but some of them were 
volunteers requesting treatment. Two of the 
facilities were large federal prison-hospitals, at 
Lexington, Kentucky, for the eastern United States 
and at Fort Worth, Texas, for the West; the others 
were specialized rehabilitation prisons operated by 
the two most populous states at Rikers Island, New 
York, and Corona, California. 

The challenges of financing and managing public- 
sector treatment have changed markedly since that 
time. Instead of four prison treatment sites, there 
are several thousand public-tier programs in 
communities and institutions in every state, 
treating well over 600,000 annual admissions and 
interacting with federal institutes, state offices, 
county agencies, elected officials, local 
bureaucracies of criminal justice, education, 
welfare, and health care organizations, and 
occasionally even private insurers. The issue 
certainly is not whether there will be large-scale 



public support for treatment but how much, what 
kinds, and for whom. 

The reasons why society has become interested in 
treating illicit drug abuse are neither strictly hard- 
headed nor purely idealistic but rather a 
combination of the two. These reasons have 
moved the public not only to permit treatment of 
illicit drug abuse and dependence in community 
settings but also to enhance the amount of 
treatment taking place by substantially reducing the 
price that the majority of individuals pay for 
treatment to well below the cost of providing it— 
often, in fact, to nothing. 

To better understand the logic by which the 
government arrives at the "right" level of support, 
it is necessary to grasp firmly the specific rationale 
for these public subsidies. The reasons for 
supporting public treatment fit comfortably within 
the realm of conventional justifications for other 
public health measures, but that is a very broad 
realm, indeed (Institute of Medicine, 1988a). In 
the case of public drug treatment, there are 
important specific emphases that ought to be made 
explicit. 



External Costs 

Individuals who can be clinically identified as 
meeting the criteria for drug treatment (whether or 
not they are interested in treatment to help 
extinguish their drug-seeking behavior) generally 
impose serious burdens on other members of 
society. The harm to victims of violent crime, the 
damages to the well-being and future prospects of 
the individual's family, the risk of transmitting 
hepatitis or HIV infection, and other such burdens 
are called externalities, or external costs. The 
problem with external costs is that, unlike the self- 
imposed consequences of actions, they do not 
automatically discipline or instruct the individual, 
which is usually the way harmful behavior is 
corrected. 



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Solutions to external cost problems ordinarily take 
one of two forms. One form is to reassign these 
costs to the individuals who produce them through 
selective taxes or confiscations, civil liability, or 
the imposition of criminal sanctions such as fines 
or incarceration. Taxing and confiscating the 
proceeds of illicit drug-related behavior have 
proved to be difficult and frequently haphazard 
endeavors; moreover, the individuals who 
originally impose the external costs are often too 
poor to pay commensurate civil or criminal fines. 
Determining an appropriate fine for transmitting 
serious and even deadly diseases is beyond nearly 
anyone's capacity. With legislatively mandated 
sentencing, the consequent sanction for such 
individuals has increasingly become jail or prison-- 
the individual is made to pay a liberty price as a 
"just desert." What this measure emphasizes is 
less the burden of harm to individual others and 
more the moral weight of the drug offense; and it 
is a moral calculus that assigns the exaction due~ 
the criminal's "debt to society." 

Nevertheless, this price may be considered 
unsatisfactory in at least two ways. In the first 
instance, the penal strategy generally does not fully 
reassign the social costs because society has to pay 
a substantial price to impose deprivations of liberty 
on unwilling individuals. Second, to date, 
imprisonment has not had enough of the desired 
effect: individuals who have paid the price of 
incarceration have all too frequently (at the rate of 
about three felons out of four) come out of prison 
and reimposed the same criminal burdens on 
society. 

There is also a third dissatisfaction. Society is 
uneasy about the strictly criminal approach to drug 
consumption. However broad the consensus on 
maintaining criminal penalties, particularly for 
trafficking offenses, the historical streams of 
libertarian and medical ideas continue to affect the 
nation's collective thinking. Although clearly in 
the minority, there are respectable voices 
questioning the entire wisdom of drug laws, even 
from within the bastions of the criminal justice 



system. In contrast, no such voices rise in dissent 
regarding laws that proscribe homicide, sexual 
assault, robbery, or grand theft (auto). 

These shortcomings of the criminal approach, in 
particular, the first two, led originally to the 
development of the public tier of treatment. As a 
result of studies in public-tier programs, which are 
reviewed in Chapter 5, there are now reasonable 
grounds to believe that at least some modalities of 
treatment do in fact reduce the external costs of 
drug abuse and dependence in greater measure 
than the cost of the treatment itself. Moreover, in 
doing so, treatment provides some benefits that 
drug-abusing and drug-dependent individuals 
themselves seek (although it often takes a 
substantial amount of exterior pressure or interior 
misery—or both— to bring them to that point) . 

This last statement brings up the second mode of 
dealing with externalities (the first being to 
reassign the external costs): design positive 
incentives to induce the persons who are producing 
external costs to stop. Incentives are a carrot that 
often accompanies the stick of penalties. The 
committee's review in Chapter 4 indicates that the 
treatment motivations of drug-abusing and drug- 
dependent individuals are usually ambivalent, with 
some degree of desire for recovery, some degree 
of pressure to avoid drugs, and some degree of 
desire and compulsion to continue seeking drugs; 
in other words, applicants show an interest in the 
benefits of treatment mixed with hostility toward 
its constraints. Under these circumstances, the 
money price of treatment may for some fraction of 
individuals play a pivotal role in determining 
whether treatment is sought or how much 
treatment is utilized. For relatively inexpensive 
treatment such as outpatient care, a partial subsidy 
may make a difference; for relatively expensive 
residential or inpatient treatment, the cost is high 
enough that a subsidy may be critical to whether 
an individual actually receives treatment. 

A complication enters here, namely, the 
relationship between public and private benefit. If 



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both the individual and society would benefit from 
the individual's positive response to treatment, 
then who should pay for it? One approach is to 
say that the answer should depend on the 
proportions of public and private benefit; a second 
is to express a strong preference for maximizing 
private payments (for example, through sliding- 
scale fees); a third strategy is to put the fullest 
onus on public payment. To be completely 
efficient in the use of public funding, one would 
want to lower prices discriminately. No one who 
is prepared to purchase treatment on his or her 
own at its market price (the cost of production plus 
markups, reserves, or profit margins, adjusted to 
competition) should be subsidized. Subsidies 
should go only to those who would purchase 
treatment at some below-market price, and the 
amount should be only what is necessary in each 
case to assure the purchase. 

If the external costs of untreated drug consumption 
(which, on average, treatment can be expected to 
reduce significantly) exceed the costs of treatment 
by a large amount and there are individuals who 
need treatment but do not want it even at zero 
cost, then the public might even find it optimal to 
create a "negative price." A negative price is an 
inducement to enter and stay in treatment that 
exceeds the minimum cost of helping clients to 
extinguish drug seeking. The extreme case of a 
negative price is cash inducement: paying people 
to enter treatment. A more palatable alternative is 
incentives in kind, such as amenities that are not 
strictly needed for treatment (even though some 
may in fact prove to make treatment more 
effective)~for example, attractive facilities, free 
coffee, or assistance in dealing with a variety of 
other social, medical, or psychological problems. 

Intrinsic medication effects may fulfill this 
incentive function. For example, clinically optimal 
levels of either methadone or naltrexone "block" 
the euphoric effects of any other opiates. But the 
very mild analgesic properties of stabilized 
methadone doses, in contrast to the virtually 
complete lack of perceptible effects of naltrexone 



maintenance, constitute a positive inducement, 
which may help to explain why methadone 
maintenance typically retains a substantial 
percentage of clients whereas naltrexone retains 
very few. 

In summary, the combination of high external 
costs and a reluctant clientele may lead society to 
want not only to provide treatment for illicit drug 
abuse and dependence at a reduced cost but even 
to provide some selected inducements, at least to 
some potential clients, that go beyond the cost of 
bare-bones treatment. (A more technical analysis 
of the issue of treatment demand and pricing is 
sketched in Figure 7-1.) 



Income Constraints 

Whether or not the external social costs equal or 
exceed—and hence begin to efficiently justify— 
treatment expenditures, there is a second major 
reason for public support of treatment: the 
problem of income constraints, or the fact that 
some people are simply too poor to afford the cost 
of treatment even if they are very interested in 
obtaining it. In some respects, society has taken 
a broad ethical position on income constraints, 
namely, that there are certain goods and services 
that should never be denied to anyone on the 
grounds of inadequate income. Generally, these 
goods and services fall into one of two categories: 
items that everyone needs at some minimum level 
but that most people can afford (e.g., food and 
shelter) and items that only a few people 
(relatively speaking) might need very badly at any 
one time but that most cannot afford at all or 
without undergoing some severe degree of 
hardship— for example, major medical care. 

Drug treatment appears to belong in the second 
category. In these kinds of cases, the government 
has both encouraged the formation of private 
compacts (using tax incentives and regulatory 
guarantees) to help the individual in need— 
employer-sponsored health insurance is the prime 



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Q 



TREATMENT EPISODES 
(in thousands) 



FIGURE 7-1 The market for drug treatment showing private and public demand. The great force of external 

cost considerations affects the whole market for treatment. If treatment episodes are expected to provide benefits to the public beyond those to the 
recipient by reducing the external costs of untreated drug problems, then that expectation should be reflected in the market by raising the demand schedule 
for treatment. In other words, at any given price, the amount of treatment demanded should be greater than just that sought by individual clients. This 
increase in the demand for treatment, which results from including the benefits to the general public , implies that the socially optimal amount of treatment 
is greater than the amount that would be provided in a completely private treatment market. 

This principle is illustrated in conventional economic terms in the figure, which is hypothetical but modeled on realistic assumptions. The purely private 
market for treatment is represented by the downward-sloping demand curve D and the supply curve S. Their intersection shows the average price, P f , 
and total quantity, Q p , of drug treatment episodes that would be delivered in the private marketplace if the government did not intervene. The public 
benefit from treatment dictates that the social demand for treatment, curve D s , is higher than the purely private demand for treatment, curve D p , and 
the quantity of treatment desired at any price is accordingly greater. When the social value of treatment is recognized in the demand schedule D t , the 
socially optimal amount of treatment is indicated by the intersection of the new demand curve and the supply curve. 

The socially optimal quantity of treatment Q s is greater than the quantity delivered in the private market Q p . To achieve utilization of treatment at the 
socially optimal level fi,, subsidization of treatment must be undertaken (by means of governmental or philanthropic subsidies) to make up the difference 
between P s , the price of inducing the socially optimal level of treatment, and P„ the average price that many potential clients would actually be prepared 
to pay for that many episodes of treatment. 



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example— and has entered directly into the 
sponsorship of such arrangements, most 
prominently in the Medicare program. But private 
insurance and Medicare share the characteristic 
that eligibility for these forms of coverage depends 
on making (or having made) ongoing contributions 
to an insurance pool through regular premiums that 
are matched by an employer and/or deducted from 
a steadily incoming paycheck. 

This form of coverage is inapplicable to 
individuals who do not belong to a private group 
health insurance plan and are too young (or 
otherwise lack qualifications) for Medicare 
eligibility. At a minimum, this group includes an 
estimated 31 million individuals who are without 
any health insurance (Moyer, 1989; cf. Chollet, 
1988). It may also include an additional 13 
million people covered by Medicaid plans and 48 
million with private health plans that lack specified 
coverage for drug treatment services. These 61 
million people are covered for emergency services 
(e.g., drug overdoses) and treatment of physical 
sequelae of drugs; many would probably be 
covered for some types of treatment of drug 
problems under general plan provisions; and some 
could afford to pay drug treatment costs out of 
pocket. In the committee's judgment, however, a 
large proportion of the 61 million individuals in 
this country without specified coverage for drug 
treatment are not covered by their health insurance 
for appropriate drug treatment in the event they 
were to need it. 

There are, in other words, at least 31 million and 
possibly 92 million individuals for whom insurance 
coverage of drug treatment may be unavailable 
when it is needed; absent stronger data, the 
approximate midpoint of this range, 60 million, is 
a reasonable figure to use. For many of these 
individuals, the out-of-pocket costs of treatment 
are formidable, particularly for residential or 
hospital treatment. The committee hazards the 
further estimate that one-third of the 31 million 
individuals who are uninsured and one-half of the 
30 million who are insufficiently covered might be 



able to afford outpatient treatment out of pocket. 
This still leaves roughly 35 million individuals 
who could not do so and who would qualify as 
indigent with regard to buying any form of drug 
treatment. For residential treatment, the 
committee's estimate of the number who would be 
considered indigent rises to 60 million. 

If society does not want to see drug treatment 
denied to persons in this group as a result of 
income constraints, the standard solution is to 
develop a scheme of differential pricing, which 
enables the relatively indigent person to pay a 
below-market price for treatment through a 
government subsidy or service program, contingent 
on an accurate determination of his or her level of 
income or wealth. The income criterion could be 
graduated according to circumstances; the guiding 
principle is that the price of treatment should be 
brought below whatever threshold rules out the 
individual being able to purchase the needed 
treatment or at which paying for treatment would 
create undue hardship. In many cases, using this 
guideline means the price must be effectively zero. 

Positive Response to Treatment 

There is a third principle besides external costs 
and income constraints that is worth mentioning: 
the treatment should do good; that is, the client 
should respond well. Of course, some do not. 
There are public clients who never achieve 
significant reductions in their drug-seeking and 
other criminal behavior (when the latter is present 
to begin with) during treatment. When those who 
are not responding well leave treatment, their 
departure cannot be called an effective result. Yet 
it does achieve the virtue of efficiency, in that no 
further money is wasted. When the public (or any 
other third party) is paying the bill for treatment, 
the most troubling problem is individuals who 
neither modify their behavior positively nor leave 
treatment. 

There are not many such people, particularly in 
the more intensive and demanding programs and 



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modalities. For the most part, people who stay in 
treatment do well as long as they are in it, and 
they either drop out or are discharged when their 
behavior deteriorates and therapeutic corrections 
(if the program makes them) are unsuccessful. 
This is not to say that most people in treatment are 
absolutely crime and drug free but that 
unmistakable improvement over pretreatment 
conditions is very much the day-to-day norm. 

In principle, there should be no coverage of 
individuals who are not expected to respond 
positively to treatment. But prognostic precision 
is simply not acute enough to draw bright 
exclusionary lines. Even previous treatment 
failure is no sure guide because the route to 
recovery often leads through several such 
misfires. 1 In drug treatment, as in virtually all 
medical care for severe, chronic conditions, the 
limited capacity to accurately predict individual 
responses dictates that this principle be applied 
sparingly, usually on a retrospective rather than 
prospective basis, therefore erring on the side of 
treating too many rather than too few. In practice, 
denial on the grounds of expected nonresponse is 
exercised very little at the point of admission; 
instead, it is a judgment made by clients (through 
voluntary attrition), by clinicians (through 
discharge decisions), or by third parties such as 
police officers (by arresting violators of the law). 



Balancing Treatment Needs and Cost Concerns 

With declining budgets the norm from the mid- 
1970s until fairly recently, one must assume that 
there will be continuing budget constraints on drug 
treatment dollars. It is difficult to believe, despite 
notable recent budget increases by the federal 
government and a few states, that the day may 

'Treatment programs do in fact exclude some people whose personal history 
is unpromising. However, these negative prognostic signs are attended to 
mostly out of a desire to minimize the risks that nonresponding behavior will 
disrupt other clients or endanger the clinical setting— for example, programs 
are leery of admitting individuals who are chronically assaultive or known 
as large-volume drug traffickers. 



come when public treatment funds overshoot the 
need for treatment. Ideally, to make the best 
decisions with limited budget dollars, one should 
look at every individual for whom a legitimate 
argument for public support could be made, 
evaluate the strength of the argument in each 
instance in terms of relative costs and benefits, and 
apply a triage or optimizing procedure to achieve 
the most efficient distribution of limited funds—that 
is, to get the greatest return on the investment of 
each treatment dollar. This triage would apply not 
only to whether an individual needed treatment but 
also to how intensive (and expensive) a treatment 
is needed for optimal results. 

However, to calculate precisely for each drug- 
abusing and dependent individual the extent of 
attributable external costs, the ability to pay, the 
relative strengths of the desire for and hostility 
toward treatment (including the potency of exterior 
and interior pressures), and the probabilities of 
response to the various treatment options is a 
complex and demanding assignment. The specific 
information needed about individual and program 
performance, the cost to collect and evaluate it, 
and the sheer conceptual challenge are all 
extensive, and there would be unavoidable residual 
uncertainties about the results, in light of the 
current and foreseeable state of the prognostic arts. 

Instead of trying to exact the last ounce of 
efficiency by fine-tuning the structure of price 
subsidies, some simpler rules of thumb may be 
(and generally are) employed. For example, 
ability to pay is usually determined by a preset 
income maximum that for convenience may be 
equivalent to local standards for welfare (and 
Medicaid) eligibility; copayments, if required, are 
graduated according to very broad income levels, 
and external cost and motivational issues are 
seldom explicitly considered in determining direct 
charges to patients (although they may be very 
important in admission and treatment planning 
decisions). Income is obliquely taken as an index 
of external costs in that low-income drug-abusing 
and dependent individuals are considered very 



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likely to resort to criminal activities to pay for 
their drugs. 

The committee believes it is clear that external cost 
and income considerations are already firmly 
incorporated into public decisions about the 
coverage of drug treatment. The external costs, 
particularly in terms of violent crime and 
increasingly in terms of harm to young children's 
lives, have been uppermost in importance. These 
considerations have been reinforced by the second 
type of concern— that treatment should not be 
appreciably less available to the poor than to the 
well-off and well-insured because it is mostly poor 
individuals who commit violent crimes and whose 
children are least protected from neglect or 
abandonment. There is a further overtone of 
concern (an echo of the 1960s War on Poverty) 
that general conditions of racial and income 
inequality might help cause and perpetuate drug 
problems and retard recovery, further reinforcing 
the urgency of public intervention. 

The principal decision criterion in public coverage 
is and should be to make publicly subsidized 
treatment available to those who are doubly needy- 
-those who most need treatment according to 
clinical criteria and who most need financial help 
to afford it. 2 Generally, having a serious need for 
treatment stands as a guarantee or, at least, makes 
it quite probable that external costs are present; 
moreover, the less the individual's legitimate 
financial capacity, the greater these external costs 
are likely to be. In general, the principle of 
covering the needy should be applied not only to 

2 Exact titration of the inability to pay. so as to marginally 
reduce public payments to those who are partially able 
financially, may be expensive and may reduce the desirable 
incentives that help draw reluctant individuals into treatment; 
in other words, the resulting revenue gains from copayment 
requirements may not be worth it. However, the introduction 
of means-based copayment requirements for long-term 
outpatient treatment, such as methadone maintenance, would 
make sense once stabilization of behavior had occurred. 
Similarly, a payback principle in kind or in dollars for successful 
graduates of therapeutic communities or other programs may 
also make sense; the prevalence of supportive "alumni groups" 
and "thirteenth-steppers" reflects this idea. 



all those who readily seek treatment but also to all 
others who can by legitimate means be induced to 
seek it. Considerations of external costs further 
argue that there is reason to create incentives 
beyond minimal coverage of bare-bones programs. 
Just as the external costs of crime justify negative 
incentives—coercion by the criminal justice system, 
which may be helpful in steering individuals 
toward treatment— these costs justify positive 
incentives to some degree, provided they can 
induce greater motivation and better retention in 
treatment. The external costs of poor job 
performance and parental deficiencies may justify 
positive incentives as well, given that criminal 
justice coercion of drug-abusing and dependent 
individuals who are steadily employed or taking 
care of children, or both, may be impractical or 
unlikely. 

In summary, the committee recommends that 
the principle of public coverage be to provide 
adequate support for appropriate and timely 
admission, completion, or maintenance of good- 
quality treatment for individuals who cannot 
pay for it, either fully or partly. Public 
coverage should be invoked whenever such 
individuals need treatment, according to the best 
professional judgment, and seek treatment, or 
can be induced through acceptable means to 
pursue it, assuming there is some probability of 
positive response. 



FROM PRINCIPLES TO PRIORITIES 

Chapter 3 concluded that the aggregate need for 
treatment in the United States at any one time in 
1988 involved about 2.5 million drug-dependent 
individuals and 3 million more individuals who 
were at least abusing drugs. Chapter 6 indicated 
that the 1987 survey of treatment providers found 
about 260,000 clients in treatment at that time, 
with total annual admissions numbering 850,000. 
Even allowing for an incomplete count of 
providers, it is clear that the need for drug 
treatment according to relevant diagnostic criteria 



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exceeds the number of annual admissions by a 
substantial amount. 3 

Given the preponderant number of treatment 
applicants who already seek help from the public 
tier, their generally low income, the prevalence of 
criminal histories among individuals needing 
treatment, and the substantial excess of supply 
over demand in the private tier (even allowing that 
this last situation has something to do with cost- 
containment pressures), the committee estimates 
that between 60 and 80 percent of those needing 
treatment for illicit drug abuse and dependence 
belong in the public tier. The apparent excess of 
current need for treatment over annual admissions 
is on the order of 2 million to 3 million 
individuals. 



above and the current status of the public treatment 
system, the committee's recommendation is that 
priority be given to the following: 

■ closing the most obvious regional gaps in 
coverage— that is, reducing delays in 
admission as evidenced by waiting lists for 
treatment; 

■ improving the average quality, 
performance, and retention rates of existing 
modalities by raising the level of service 
intensity, personnel quality, and experience; 
by having programs assume more 
integrative roles with respect to related 
services; and by instituting systematic 
performance monitoring and follow-up; 



This disproportion between the need for treatment 
and the number of people receiving treatment 
seems inconsistent with indications that more 
potentially usable treatment resources are on hand 
in some states (and in some programs in other 
states) than are being utilized. Much of the 
disproportion is attributable to the circumstance 
that needing treatment is not the same as wanting 
it or being able to pay for it, either individually or 
with assistance. But bringing these elements into 
better balance is not a simple task. For one thing, 
despite the recent large increases in federal 
appropriations for treatment, there is clearly not 
enough money actually available as yet in the field 
to implement the principles summarized above. 
And even if the budgetary commitment to that end 
were firm, creating actual effective treatment 
capacity will take time, trial and error, and hard 
work. Priorities must be established. Where 
should new monies and energies go first? 

This choice is clearly a matter of informed 
judgment. In light of the principles articulated 



3 Of course, there are also dynamic considerations: 4 million 
young people newly enter the prime onset period each year, 
and an unknown number leave the drug scene. Appendix 7B 
contains some additional comments on the need for dynamic 
analysis. 



expanding treatment through more 
aggressive outreach to pregnant women and 
young mothers, those for whom it promises 
the greatest potential reduction in external 
social costs; and 

further expanding community and 
institutionally based treatment services to 
provide treatment to drug-abusing and 
dependent individuals under criminal justice 
supervision. 



Eliminate Waiting Lists 

There are individuals who want treatment now as 
it is currently offered but who are stymied by the 
constraints on its availability. The best estimate of 
the number of such individuals comes from a 
survey of 43 states conducted by the National 
Association of State Alcohol and Drug Abuse 
Directors (NASADAD) in September 1989, which 
indicated that 66,000 individuals were awaiting 
treatment admission. This figure is equivalent to 
more than a quarter of the total daily enrollment in 
public-tier programs. 



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The 1988 Anti-Drug Abuse Act included a one- 
time grant program providing $100 million for the 
reduction of waiting lists. Because this is a one- 
time allocation, many programs have been leery of 
applying for the funding: the implication of 
expanding admissions is to commit to additional 
space and staffing, and such a commitment would 
fly in the face of the nonrenewability of these 
funds. Programs that have waiting lists have 
found that when they are able to accelerate 
admissions as a result of expanded capacity, they 
attract even more applications. The committee 
believes it is more realistic to consider current 
waiting lists a minimum estimate of the sustained 
size of additional interest in treatment and 
therefore to anticipate a continued increase in 
service requirements that is at least equal to 
current waiting lists. 



Improve Treatment 



The upgrading of program performance and 
quality levels is intrinsic to the other priorities and 
would be needed even if expanded treatment 
admissions were not an objective. The recent 
diminution of treatment program resources from 
the middle 1970s to the late 1980s hobbled many 
programs' capacity to provide treatment as 
effectively as the state of the art permitted. 
Research findings about large variations in 
program performance and the consistent 
importance of retention in predicting outcome all 
support the need to upgrade per capita funding, 
quality, and retention levels in treatment. 

The evidence on the specific components of drug 
treatment effectiveness and attractiveness is 
beguiling but slender. One must depend to a large 
extent on a few careful studies done in methadone 
programs, on the judgment of experienced 
clinicians, and on organizational common sense. 
Some of the personal characteristics, skills, or 
procedures followed by individual drug counselors 
make a measurable difference in their clients' 



performance. Other professionals can usually 
detect or recognize these qualities (although in the 
absence of definitive studies, they differ in how to 
describe them), and there is a market for good 
therapists whose talents have been honed on 
difficult cases, such as drug-dependent criminals. 
Traditionally, clinical staff in public programs are 
attractive recruits for private practices or agencies 
that offer higher pay and a less demanding 
clientele. 

Moreover, staff who are overloaded with cases and 
working in organizations that are underendowed 
with positive incentives sometimes "burn out": 
they may simply lose their enthusiasm and 
effectiveness or actually leave the program. 
Incentives and tools for upgrading clinical 
practices, which were a critical part of the agenda 
of public-tier programs in the early 1970s, have 
been casualties of retrenchment; in particular, 
periodic retraining and technical assistance and 
well-designed systems of performance monitoring 
diminished and nearly disappeared in the 1980s. 

The chronic inability of public programs in recent 
years to keep caseloads within reason and to attract 
or retain the best counselors is a fundamental 
problem that more per capita funding can help 
solve. The same solution applies to reversing the 
erosion of clinical tools and service intensity. A 
prominent program need is to be able to afford 
more frequent and more accurate random drug 
tests whose results are available quickly. Of at 
least comparable importance is the systematic 
multidimensional assessment of client needs and 
the provision, where indicated, of vocational, 
educational, and specialized psychiatric and 
medical services; these services may be provided 
either by incorporation of such capacities into the 
program or by referral (particularly, funded 
referral) to other service agencies and systematic 
follow-up with them. For example, treating 
cocaine requires increased use of physicians, 
nurses, and pharmacists to monitor the early stages 
of treatment because emerging therapies for 
cocaine dependence often incorporate transitional 



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medications that, until much greater experience has 
accumulated, will continue to need individualized 
prescribing. 

The upgrading of staff abilities and morale and the 
modest but critically needed renovation of decrepit 
facilities and furnishings have multiple 
significance. Good morale and decent facilities 
increase the attractiveness of treatment programs 
and thus their ability to recruit and retain effective 
staff and effectively motivated clients. Most 
critically, the competence, quality, and continuity 
of care givers may well be a critical element in 
explaining the differential effectiveness of 
treatment programs. 



Reach More Young Mothers 

The committee attaches high priority to treating 
expectant mothers and single women with young 
children. The external costs of drug abuse and 
dependence among this group are especially 
worrisome because these children's present and 
future welfare depends so heavily on their 
mothers' welfare. High risks of drug problems 
and other severe dysfunctions inhere in children of 
parents who are abusing or dependent on illicit 
drugs. Consequently, the committee values 
children's welfare on both an equity basis— they 
obviously have very limited ability to help 
themselves because of their physical immaturity, 
lack of personal income, and inexperience— and in 
terms of the future social costs that it is strongly 
suspected these children will bear. 

Site visits by the committee demonstrated that it is 
especially hard for expectant women or single 
mothers of young children (and often, women are 
both) to receive intensive residential treatment, and 
sometimes even to maintain regular outpatient 
schedules, because of child care needs and other 
medical and social problems. The committee 
believes that any initiative to bring more of these 
women into treatment must also emphasize 



dwellings in which to live and productive activities 
for themselves and their children. 

The problem of pregnant women who take illicit 
drugs has received a great deal of attention 
recently. Although no study has specifically 
examined the number of expectant mothers in drug 
treatment, applying the roughly 10 percent annual 
fertility rate for women demographically similar to 
those currently in treatment indicates that about 
30,000 expectant women receive some drug 
treatment each year— very few of them in programs 
with a primary focus on and special services for 
pregnant women. The committee estimates that 
105,000 pregnant women a year need treatment. 
There is no basis to believe that treatment of these 
women would be appreciably more or less 
effective than for other adult clients. But even if 
the distribution of results is the same as for others 
in terms of extinguishing drug-seeking behavior, 
that outcome would be worth pursuing more 
intently because of the external costs to the 
children. 

Reaching more pregnant women will require active 
and expensive outreach. One demonstration 
outreach project in Harlem, New York (Brown, 
1988), cost $850 per expectant mother enrolled in 
prenatal care, an expenditure completely apart 
from the cost of drug treatment and prenatal care 
services as such. Pregnant women are likely to 
require relatively more intensive residential 
treatment than most clients owing to the special 
risks they pose to their babies and their aversion to 
treatment. For pregnant women with older 
children and other single women in treatment, 
onsite care for dependent children is a critical 
treatment-related need. It is often a major obstacle 
to enrolling and staying in intensive residential or 
day treatment because very few programs at 
present have onsite child care. Despite the stories 
of abandonment and grave concerns voiced (most 
often by male professionals) about the "destruction 
of the maternal instinct" by cocaine dependence, 
most mothers will not stay in treatment for long if 
it means separation from their children. 



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TABLE 7.1 Three Strategy Options for the Public Tier of Drug Treatment: Estimated 
Incremental Costs and Client Projections Relative to 1989 



Strategy Type 


Cost Element 


Core 


Comprehensive 


Intermediate 


Annual Costs" 








Reduce waiting list 


330.0 


330.0 


330.0 


Restore funding 


412.5 


412.5 


412.5 


Counselor training 


19.6 


30.1 


24.9 


Performance data 


75.9 


112.8 


94.4 


Expectant mothers 








Outreach 


18.8 


112.5 


56.3 


Treatment 


87.9 


263.7 


175.8 


Child care 


45.9 


77.5 


61.7 


Probation/parole 


0.0 


660.0 


330.0 


Prison 


0.0 


156.3 


78.1 


Total 


990.6 


2,155.4 


1,564.5 


One-Time Investments" 








Expand residential facilities 


278.8 


746.2 


512.5 


Renovate residential facilities 


90.0 


90.0 


90.0 


Renovate outpatient facilities 


118.1 


118.1 


118.1 


Train new staff 


33.2 


116.8 


75.0 


Total 


520.1 


1,071.1 


795.6 


Number of Clients Served 15 








Average daily census 


387 


607 


497 


Total annual admissions'* 


1,012 


1,505 


1,258 



"In millions of 1989 dollars. 

b ln thousands. 

The average daily client census in 1987 was 212,000; it was estimated at 275,000 in 1989. 

d Total annual admissions to public-tier treatment in 1987 were 636,000; total admissions for 1989 were 

estimated at 815,000. 

Source: See Appendix 7B for calculations. 



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Induce More Criminal Justice Clients 
to Accept Treatment 

In 1985 about 25 percent of public-tier clients in 
14 states were under probation or parole 
supervision; extrapolated to the national level, this 
percentage translates into a census of 55,000 or 
about 160,000 annual admissions of community- 
based criminal justice clients. In addition, 30,000 
to 50,000 prison inmates were in treatment— 
although these estimates include less specialized 
counseling, education, and mutual self-help group 
meetings. These figures indicate a 10 to 20 
percent rate of treatment among criminal justice 
clients who need treatment. 

These individuals constitute the group whose 
imposition of high external costs represents the 
primordial raison d'etre of the public tier. 
Because of the flooding of criminal justice 
channels during the past decade and a half, the 
induction into drug treatment of suitable, younger 
criminal justice clients has lagged behind the rates 
achieved in the 1970s. Yet a central lesson of 
Chapters 3, 4, and 5 is that treatment, far from 
being antithetical to the criminal justice system, is 
complementary to it, sharing its principal goals 
and offering a resource that may permit more 
efficient use of enforcement, correctional, and 
judicial facilities and resources. Although there is 
no way to substantiate this impression, the 
committee deems it plausible that the erosion of 
resource intensity and surveillance capacity within 
treatment programs during the period of 
retrenchment in the 1980s contributed to the 
increasing pressure on the criminal justice system, 
particularly from probation and parole violators. 



THREE STRATEGY OPTIONS 

The public tier is now on a rapid expansion 
course, largely as a result of decisions at the 
federal level. This expansion began in a moderate 
way with the 1986 Anti-Drug Abuse Act, gained 
momentum with the 1988 Anti-Drug Abuse Act, 



and accelerated even more dramatically with the 
emergency supplemental appropriation to the 
alcohol, drug abuse, and mental health services 
(ADMS) block grant and related demonstration 
authorities late in 1989 (see Table 6-3). The 
Office of National Drug Control Policy, which was 
legislatively authorized and established in March 
1989, has been assigned a leading role in national 
strategic planning for drug treatment (as well as 
enforcement, interdiction, and prevention), 
whereas the Alcohol, Drug Abuse, and Mental 
Health Administration (ADAMHA) in September 

1989 consolidated the block grant and many of the 
treatment demonstration authorities in the Office of 
Treatment Improvement, which has not yet 
received congressional ratification. 

To date, however, there is no settled, detailed plan 
for this expansion course, although the January 

1990 National Drug Control Strategy does identify 
eight national drug treatment funding priorities 4 
and budget figures for fiscal years 1991-1993. 
Congress has shaped the block grant and 
demonstration appropriations through 1986 and 
1988 amendments to the ADAMHA authorization 
codes, but that process is incomplete; a set of 1990 
amendments that are currently under committee 
consideration may entail more sweeping changes in 
the structure of the federal money streams and 
targets. 

To inform and provide a common reference point 
for these policy formulation processes, the 

4 The eight priorities are as follows: increased availability and 
quality in drug treatment; additional vocational counseling, 
training services, and aftercare for recovering addicts; improved 
and expanded outreach and treatment services for pregnant 
women and drug-affected infants; expanded availability of 
treatmentservices within correctional institutions; development 
of innovative approaches to drug treatment, including drug 
treatment campuses and special programs targeted toward 
adolescents and pregnant women; expanded fellowship and 
grant programs for drug treatment professionals and staff; 
establishment of the Office of Treatment Improvement within 
the Department of Health and Human Services to focus on drug 
treatment quality and effectiveness; and enhanced treatment 
research, including expanded data collection, medications 
development, and evaluation of current treatment methods 
(Office of National Drug Control Policy, 1990:28). 



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committee has developed three detailed strategy 
options based on the priorities it recommends for 
adoption: 

■ A core strategy, to deal with existing 
waiting lists, remedy deficiencies in 
program quality and management, and 
implement modest program initiatives for 
young women with children. The core 
strategy would exceed 1989 levels of 
public-tier operating support by about $1 
billion, plus $0.5 billion as an additional 
one-time investment for staff training 
and facilities construction and 
renovation. 



1989 public outlays by state, federal, and local 
agencies; the detailed calculations required to 
arrive at these figures are provided in Appendix 
7A. It should be noted that the data supporting the 
costs and results of proceeding along any of the 
recommended option lines have many 
uncertainties. As relevant data collection 
processes are improved and analytical research 
performed, the models underlying these cost 
estimates will, over time, be capable of 
adjustment. 



The Core Strategy Option 



■ A comprehensive strategy, adding to the 
core plan a substantially greater 
induction of criminal justice clients and 
a more ambitious plan for treating drug- 
abusing and drug-dependent mothers; 
this comprehensive plan would, in the 
committee's judgment, provide the 
optimal level of public treatment 
resources. The comprehensive plan 
would entail an annual operating 
increase over 1989 levels of about $2.2 
billion, plus a $1 billion one-time 
investment. 

■ An intermediate strategy following 
between the core and comprehensive 
approaches. The intermediate proposal 
would cost about $1.6 billion, plus a $0.8 
billion one-time charge. 

To estimate the amount of new public financing 
needed to carry out each of these strategic options, 
the committee made some key assumptions about 
such parameters as capital costs, training expenses, 
the number of individuals who could be induced 
into treatment at various levels of effort, and the 
costs of improving treatment performance. The 
costs and expected numbers of clients to be served 
are summarized in Table 7-1 . The dollar amounts 
are defined in terms of increases over estimated 



The core option focuses on three of the four 
priorities noted earlier: reduction of waiting lists, 
improvement of treatment quality, and dedicated 
efforts to treat expectant mothers and provide 
onsite child care for other parents of young 
children. 

The $330 million estimated cost of the waiting list 
reduction is based on increasing the daily treatment 
enrollment by 66,000, which corresponds to the 
estimate of the NASADAD survey of 43 states in 
September 1989. The committee calculated the 
cost of these additional treatment spaces assuming 
that per capita funding would be restored to 1977- 
1979 levels and that this restoration would increase 
retention rates by about 10 percent. There is also 
funding allotted for one week of specialized annual 
training or equivalent staff development 
programming for every clinician and budgeting to 
implement a comprehensive treatment performance 
monitoring system that includes intake, discharge, 
and postdischarge/follow-up data collection and 
analysis on a sample basis. 

Also included in the core strategy option is the 
cost of outreach directed toward pregnant women 
who need treatment and targeted increases in 
treatment capacity appropriate for this group, with 
an aim to reaching 25 percent of the committee's 
annual untreated prevalence estimate, which is 



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75,000 women. Finally, the plan includes an 
allocation for child care for women in public 
residential programs, including pregnant women 
with older children. 

The estimated $1 billion incremental operating cost 
of the core option nearly doubles estimated 1989 
public outlays for treatment; in addition, there is a 
need for one-time investments in new facility 
acquisition and construction, long overdue 
renovation of older clinical sites, and initial 
training for new staff. The committee considers 
these supports to be critically important in 
avoiding dilution of the effectiveness of other 
efforts to upgrade treatment quality. This one-time 
set of expenditures need not be made in a single 
year; however, it cannot be stretched over more 
than three years without creating a bottleneck in 
terms of effective treatment capacity. 



Comprehensive and Intermediate 
Strategy Options 

The comprehensive option requires approximately 
double the operating increment and one-time outlay 
of the core plan. Virtually all of this difference is 
accounted for by two particular initiatives and their 
implications for staffing, facilities, and related 
services. One of these initiatives is a large-scale 
push to induct into treatment many more 
individuals who are under criminal justice 
supervision. Although many waiting list clients 
and some of the pregnant women to be added to 
treatment censuses under the core plan are under 
criminal justice supervision, there would not be 
enough of them under the core expansion to make 
an appreciable difference in the operations of the 
criminal justice system—that is, to build up the 
complementarity that the courts and correctional 
agencies need to improve the management of their 
own responsibilities. The committee projects an 
increase in daily treatment enrollment of 132,000 
parolees and probationers, which would bring 
annual admissions to a figure that exceeds half of 
all those estimated to need treatment. In the 



committee's view this increase probably pushes to 
the outside limit the number of criminal justice 
clients who can be induced or pressured into 
entering treatment under existing coercive 
structures. 

The committee also projects enrolling 50,000 
prisoners in new comprehensive yet drug-specific 
programs. Although this figure is double the 
highest current estimate of prisoners in treatment, 
it may well be that the actual number of people in 
recognizable drug treatment modalities is much 
smaller, making this in fact a very large 
increment— again pushing the outside limit of what 
is possible. Although prisoners might seem an 
easy lot simply to order into treatment— a truly 
captive audience— it is evident that there are many 
older prisoners who have tried treatment more than 
once before and do not like it. It is 
constitutionally dubious and hazardous to 
correctional safety to try to increase greatly the 
amount of coercion used on people who are 
already in prison. The most fundamental 
disciplinary sanction in prison is length of time left 
to serve, but under mandatory release legislation, 
court orders to limit overcrowding, and the 
multiple tensions that stain the social order of these 
"total institutions," manipulation of this sanction to 
serve any imposed purpose must follow a cautious 
path. 

The committee has set the number of expectant 
mothers to be reached and treated in a 
comprehensive strategy at 57,250, or three- 
quarters of the number estimated nationally to need 
treatment but who are not now receiving it. This 
figure also seems to be an outer possible limit, a 
view conditioned by the formidable difficulties that 
prenatal outreach programs have experienced in 
trying to induce less severely impaired and 
dysfunctional populations to enter prenatal care 
programs, which make far fewer demands on time, 
concentration, motivation, or level of organization 
than drug treatment would. 



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The intermediate option needs little additional 
comment. It basically splits the difference between 
the core and comprehensive strategies, adopting a 
more conservative level of effort than the 
comprehensive strategy to induce the criminal and 
maternal populations to enter treatment. 



PUBLIC INTERVENTION IN THE 1990s 



Whatever strategy options or levels of expenditure 
emerge in the next few years, three basic issues 
will need to be faced by those responsible for 
organizing and managing the publicly funded 
treatment system. 

■ The first issue is how responsibilities 
should be allocated among the different 
levels of government and especially 
between the two levels that have taken the 
major responsibilities for financing public 
treatment: the federal government and the 
states. 

■ The second issue is which financial 
mechanisms should be used. The 
fundamental choice lies between two 
models that have dominated public support 
of health care services and certain other 
welfare services: the public health 
insurance approach and the direct service 
approach. Public insurance is a 
commitment to the individual from the 
government to reimburse certain kinds of 
treatment costs wherever the individual 
incurs them (within certain limits). In 
direct service the government arranges to 
support particular providers directly, who 
are then open to serve any individuals 
meeting stipulated criteria for the receipt of 
subsidized care. 

■ The third issue is what kinds of controls, 
disciplines, and incentives should be used 
to ensure that specific expenditure decisions 



will be appropriate and effective. The 

concerns here are fiscal prudence, cost 

containment, and quality assurance and 
control. 

The committee believes that the most informed 
judgment on how to resolve these issues effectively 
must begin with a careful consideration of the 
lessons of the recent past, namely, how these types 
of questions were handled in the period of the last 
"war on drugs" and its aftermath in the 1970s and 
during the block grant period of the 1980s. 



Federal and State Roles in the 1970s 

The high point of centralized federal command of 
the drug treatment system was the early 1970s, the 
period of SAODAP— the Special Action Office for 
Drug Abuse Prevention (Table 7-2; also see 
Chapters 2 and 6 and Besteman in volume 2). 
SAODAP negotiated directly with local treatment 
providers to set them up to provide treatment or to 
"buy" their waiting lists through increased 
funding. It specified the nature of the treatments 
to be delivered, set reimbursement rates based on 
those specifications, provided technical assistance 
to program managers, and organized and delivered 
clinical and management training to treatment 
staff. It also created a nationally standardized 
Client-Oriented Data Acquisition Process 
(CODAP) that was capable of monitoring the 
performance of treatment programs in terms of 
admission characteristics, retention, and patient 
status at discharge. 

Nevertheless, it was clear to the federal managers 
that close supervision of a national system that was 
rapidly growing and had already passed 100,000 
daily clients (treatment slots) was really beyond the 
scope of a small, albeit powerfully positioned 
federal agency. As rapid growth outstripped 
SAODAP's capacity to maintain oversight, the 
strategy was to "seed and cede"; that is, build 
community programs to what seemed an 
appropriate size and then turn over their further 



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TABLE 7.2 Chronology of Major Policies Toward Drug Treatment 

Year Event/Policy 

1 930s Federal prison hospitals opened at Lexington and Fort Worth. 

1962 California and New York addiction initiatives-These measures authorized pretrial civil commitment to 
treatment; an integral component was intensive, long term, community-based supervision. 

1 966 Narcotic Addict Rehabilitation Act-This legislation authorized federal pretrial civil commitment, voluntary 
self-commitment, and federal support of community-based supervision/treatment through a grant-in-aid 
program; it constituted the foundation for the future federally funded grant-in-aid program. 

1967 The City of New York proposes expanding a small network of methadone clinics to 25,000 slots. 

1969 An investigative new drug (IND) application is made for methadone by the National Institute of Mental 
Health. This allowed methadone programs to be established under the umbrella of mental health centers 
as part of the process leading to full Food and Drug Administration (FDA) approval of methadone 
maintenance in 1972. 

1971 Executive Order 11599 establishes the Special Action Office for Drug Abuse Prevention (SAODAP) 
designed to organize, direct, and evaluate the federal drug treatment effort. 

1972 The Drug Abuse Office and Treatment Act (P.L. 92-255)--Congressional authorization is given for 
SAODAP; the act also provides a major increase in support for community-based treatment, authorizes 
formula grants for directing funds to states, and requires the designation of a responsible state agency 
for submission of a state drug abuse treatment plan. 

1972 The federal government "buys up" waiting lists of local treatment agencies to expand the treatment 
system. 

1973 The National Institute on Drug Abuse (NIDA) is established to collect under one roof all of the disparate 
treatment and prevention services (funding, technical assistance, system monitoring, training, etc.) and 
research functions. 

1975 NIDA converts the statewide services contracts to grants, which provides the states with important 
resources and authority in managing local treatment contracts. SAODAP is terminated. 

1981 Omnibus Budget Reconciliation Act--This legislation ends categorical grants, converting them to block 
grants and reducing federal effort by 25%. All federal support for community-based treatment is now 
funneled through block grants; states assume all responsibility for managing the treatment system, 
including technical assistance, quality assurance, and training. NIDA staffing level greatly reduced. 
Federal support declines over the next several years, from about 40% to about 20% of total treatment 
funding. 

1 986 Alcohol and Dug Abuse Amendments of 1 986 (Title IV of Anti-Drug Abuse Act of 1 986)--This legislation 
renews the federal commitment to treatment, approximately doubling federal funds through supplemental 
block grant appropriations and new demonstration authorities. 

1 988 Comprehensive Alcohol Abuse, Drug Abuse, and Mental Health Amendments Act (Title II of Anti-Drug 
Abuse Act of 1 988)--This act continues the federal commitment to treatment and provides for increased 
federal involvement in monitoring of the system, as well as one-time grants for waiting list reduction. 

1 989 An emergency appropriation is attached to the Transportation Bill; it supplements the block grant, adding 
half as much again to the annual substance abuse treatment and prevention allocation. 



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supervision and the responsibility for financial 
support largely to other authorities, predominantly 
at the state level. 

The devolution of the national treatment system to 
52 state-level systems (the 50 states plus 
Washington, D.C., and Puerto Rico) advanced 
sharply in 1975, when virtually all of the treatment 
and prevention authority of SAODAP (which was 
then being disestablished) was fully transferred to 
the National Institute on Drug Abuse in the 
Department of Health, Education, and Welfare. 
NIDA converted all direct contracts with treatment 
providers into grants, which implied less federal 
direction and greater autonomy for the treatment 
programs. At the same time, additional resources 
and authorities were directed to "single state 
agencies" designated to take over most of the 
management responsibilities for administering 
federal funding for treatment; by 1981 nearly 90 
percent of federal support to community-based 
treatment was routed through the state agencies, 
mainly in the form of statewide formula grants. 

Between 1975 and 1981, federal support for drug 
treatment services flagged, initially under pressure 
of the 1974-1975 recession and climbing federal 
deficits. Nominal federal treatment dollars 
remained relatively stable from 1976 through 
1980, which, in the face of unprecedented 
inflation, meant that federal support for the system 
was steadily decreasing. Federal funds were 
generally available to the state agencies on the 
basis that states had to at least maintain their own 
current levels of appropriation for treatment, 
although no specific matching-type provisions were 
involved once the conversion from program-level 
support to using the state agencies as 
intermediaries had taken place. 



The 1980s: Block Grants 

The 1981 Omnibus Budget Reconciliation Act 
(OBRA) accelerated state control of the national 
treatment system and completed the transition of 
NIDA's mission to one of purely research and 
educational functions. All community -based 
categorical funding was consolidated within a 
block grant that covered alcohol, drug, and mental 
health services— the ADMS block grant, which was 
administered by NIDA's parent bureau, 



ADAMHA. The total ADMS funding for each 
state was reduced by 25 percent from the previous 
year's equivalent funding (the official rationale for 
this reduction being that the system would be that 
much cheaper to manage after consolidation; state 
officials, among others, considered this rationale 
not even remotely plausible), and the division of 
funds among the states was frozen at the previous 
year's proportions of the equivalent funding. The 
block grant did not require any particular state 
contribution, but it continued to require that states 
not use the new no-strings federal funding to 
supplant state support for the same functions— 
basically putting a floor under state support for 
total ADMS functions. 

As the federal role in treatment, outside of basic 
and clinical research, was reduced to certifying 52 
Treasury vouchers, the states acquired virtually 
sovereign responsibility for the shape and vitality 
of the public tier. This responsibility included 
deciding how much drug treatment would be 
provided out of the combination of ADMS funds 
and state appropriations, allocating monies among 
programs and localities, maintaining or revising 
treatment protocols and staffing and other 
requirements, monitoring program performance, 
delivering technical assistance and training 
services, and setting reimbursement rates. Many 
states, however, redirected money for these 
purposes, as well as authority and responsibility, 
to their constituent counties. 

Federally managed data systems that had 
monitored treatment were discontinued, leaving 
only a semblance of national information about 
how treatment dollars were being spent and to 
what effect. There was, for example, a 5-year 
interregnum in the survey of treatment providers 
(NDATUS), an end to the national client research 
sample (TOPS), and closing down of the client 
data requirements (CODAP), although some states 
elected to retain elements of the CODAP system 
and provide data summaries to NIDA. 

Federal appropriations to the block grant fund 
changed modestly between 1982 and 1986, and 
federal inflation-adjusted support declined further. 
State appropriations generally increased, however, 
depending on local economic conditions and the 
severity of the state's drug problem. In aggregate, 
state and local funds by 1987 were about double 



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the federal contribution (see Figure 6-7b). During 
this period Congress instituted several categorical 
set-asides and minimum proportions for types of 
services within the block grant—for example, a 35 
percent minimum expenditure each for drug and 
alcohol treatment— which marginally narrowed state 
autonomy in spending block grant funds. 

With the Anti-Drug Abuse Act of 1986 came a 
significant boost in federal support for treatment, 
nearly doubling the federal funding nominally 
allocated to drug treatment, adding an alcohol and 
drug abuse treatment and rehabilitation (ADTR) 
block grant on top of the ADMS grant, and 
implementing other increases as well. The act 
specified that a combination of the size of the 
population and documented estimation of the need 
for treatment would be used to determine the 
allocation per state. The legislation indicated 
Congress's concern over the lack of data on the 
national treatment system by setting aside 1 
percent of block grant funds for collecting 
evaluation data and requiring states to develop and 
submit plans for their anticipated use of block 
grant funds and evaluation of the impact of the 
additional treatment funds provided through the 
ADTR. Yet there was no federal response 
contingent on such plans or evaluations. The 
federal office could not really question or 
disapprove state plans, and there was no 
mechanism of accountability, that is, no way to 
determine whether the plan was followed or what 
the results were. There was no fundamental 
change in the organization or management of the 
system. 

The Anti-Drug Abuse Act of 1988 further 
increased federal appropriations and began to 
rebuild some national analytical capacities and 
flexibilities. It added more categorical set-asides 
mandating how the money could be spent, again 
cutting into state autonomy. These set-asides 
included a requirement that 20 percent of the 
substance abuse part of the grant be allocated to 
prevention activities, 20 percent of the total be 
spent on women, and at least 10 percent of the 
drug portion be spent on treating problems 
involving intravenous drugs. With this act came 
a congressional mandate for the Department of 
Health and Human Services to set aside 5 to 15 
percent of the grant to collect data about the 
operation of the national treatment system and give 



ADAMHA authority to resume making unmediated 
demonstration and service grants to local programs 
and governments, without regard to the block 
formulas for state-by- state division of funds. 
There was a one-year appropriation for the 
purpose of grants to reduce waiting lists. The 
1988 act also created the new Office of National 
Drug Control Policy, with broad coordinative 
authority over federal budgets and activities. 

At the end of 1989 an additional appropriation, 
attached to a major transportation bill, increased 
the alcohol and drug block grant appropriations by 
nearly 50 percent over the 1988 levels. However, 
a series of proposed accompanying changes in 
specific authorization levels were not passed. 
Despite the concern of Congress evidenced in the 
1986 and 1988 acts over the state of the treatment 
system, and despite various perceived efforts to 
improve information and tighten federal control, 
the balance of responsibility between state agencies 
and the federal government has not materially 
changed from the roles each assumed in 1981. 



The 1990s: Appropriate Shifts 
in Federal and State Roles 

The committee has recommended— on the grounds 
of reducing external costs and helping the poor— 
that drug treatment be made universally accessible 
and even attractive when it is clinically 
appropriate. To achieve this objective, it seems 
necessary now, as it was in the early 1970s, for 
the federal government to undertake a major near- 
term expansion of its financial commitment to drug 
treatment. This expansion is clearly a 

responsibility that Congress and the Bush 
administration have agreed is appropriate, although 
there are differences with regard to what this 
commitment should be in dollar terms and some 
uncertainty about how best to organize the effort. 
With the new increases in federal funding, it is 
appropriate that there be a realignment of the 
federal role. But unlike the situation during the 
SAODAP era, there is now in place a series of 
well-developed state administrative capabilities and 
a large base of public treatment on which to build. 
Further building will require that federal executive 
authority be deployed again but with a much more 
complicated agenda than in the earlier period. 



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In carrying out this expansion, the committee 
believes that two major considerations- 
management tasks for the federal government- 
pertain: 

■ federal drug treatment funds must be spent 
efficiently and coordinated effectively with 
other elements in the "war on drugs," 
including related social, health, 
rehabilitative, and correctional services; 
and 

■ the drug treatment system must be clearly 
linked with other forms of state and 
federal cooperation to assure the 
integration of drug treatment with other 
health and welfare services. 

The first management task applies in the short 
term— the next three to five years. The committee 
has serious doubts that the block grant system and 
its current spending formulas are the best way to 
use federal authority under the current 
circumstances. It seems unwise to simply pump 
major funding increases through the current 
mechanisms without revising the distribution of 
authority so that greater responsibility and 
accountability requirements can flow along with 
greater sums of money. This task can be fulfilled 
best, in the committee's judgment, by a strong 
federal program of categorical spending— the 
direction in which the block grants are already 
moving as categorical spending floors, set-asides, 
and data requirements are attached to them. The 
federal program, however, needs to have as much 
flexibility on the management level as possible to 
permit the responsible federal offices to adapt 
rapidly to the varying needs and administrative 
environments of states and their localities. 
Without that flexibility, it is difficult to see how 
the federal offices can be responsive and be able to 
facilitate the states' responses to such priorities as 
treating more women and criminal justice 
populations and creating performance improvement 
factors and measurement systems. 

The financing mechanism that appears most 
appropriate for achieving these managerial tasks in 
the near term is neither block grants hedged in 
with formulas nor federal demonstration grants to 
providers but rather categorical support of 
treatment programs administered through state 



agencies by a mechanism like the former statewide 
services grants or contracts used in the 1970s. 
The state agencies in turn should develop 
cooperative agreement-type mechanisms to ensure 
the involvement of and coordination with 
appropriate units of state and local government and 
community-based programs. The importance of 
state agency coordination and accountability was 
recognized by ADAMHA in allocating a 
substantial evaluation factor (20 points out of 100) 
to "umbrella grant" proposals for the waiting list 
funds authorized in the 1988 Anti-Drug Abuse 
Act. 

Cooperative agreements can be multilateral, 
involving multiple levels of government. When 
the SAODAP expansions of federal funding 
occurred and money began going directly to 
providers, the federal office found that it could not 
expect to expand its staff enough to monitor these 
programs successfully but had to seek 
intermediaries— the state agencies— for this task. 
Because the states were already directly involved 
in managing the system, they compensated for 
some of the decline in federal support that 
occurred in the early 1980s and in fact became a 
substantially larger source of funds than the federal 
government. 

In lieu of fixed formulas for the allocation of funds 
received by the states (which, as most recently 
revised, are based on population weighted 
somewhat by degree of urbanization), the 
committee recommends that state agencies be 
required to submit plans that analyze the 
conjunctions and mismatches among the most 
current epidemiological information and known 
treatment capabilities; it further recommends 
that the states propose annual spending patterns 
that reflect this information. Formally defined 
and state-certified addiction treatment programs, 
and not individual practitioners, should continue to 
be the recipients of public grants and contracts for 
addiction treatment. In addition, a portion of the 
federal dollars must go into technical assistance 
and data system building to ensure at the state, 
local, and program levels that this planning effort 
will have a factual basis. 

As performance data systems come on line, data 
should be reported in the following period to 
indicate whether actual spending details depart 



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from the plan, and why, with analysis, 
explanation, and adjustment in the subsequent 
plan. The focus initially needs to be on 
improvement and response rather than punishment 
(such as shifting federal funds to mechanisms that 
bypass state or local intermediaries), but the 
objective of coming into line with performance 
standards should apply without much delay. An 
independent analysis of each state's performance 
with respect to its planning goals and control of 
resources should be developed and submitted in a 
report to Congress on an annual or biannual basis. 

Taking a longer term view, the general pattern of 
federal initiatives has been to pour money into 
categorical programs, then consolidate those 
programs to reduce the natural accretion of 
paperwork requirements on recipients and to cap 
or reduce federal expenditures. Direct categorical 
funding is the best way to build service capacity 
rapidly, but historical experience shows that only 
by making a transition from narrower categorical 
programs to broader spectrum funding can quality 
programs be maintained at suitable service levels. 
The risk in direct categorical support is that 
recipients and intermediaries will not move toward 
a self-sustaining, self-adjusting system. When the 
federal government reduces its funding and direct 
management involvement, as it inevitably will, the 
tasks of coordination, accountability, and 
adjustment may suffer, to the detriment of 
beneficiaries and the public interest. 

Therefore, a longer term goal (the next 5 to 10 
years) must be kept in view from this point 
forward in building up the treatment system: 
namely, to move the mechanisms for funding drug 
treatment away from central reliance on direct 
service support and toward consolidation with the 
mainstream of health care financing for low- 
income populations, which is the Medicaid system. 
During the 1980s the growth of private health 
insurance coverage for drug treatment brought the 
private tier and its insured clients into the 
mainstream of health dollars, and although this 
movement has not been complete, fully efficient, 
or without troubles in various respects (as 
discussed in Chapter 8), it has unquestionably 
improved accessibility to treatment for those 
covered by private insurance. It is time to 
stimulate a similar process across the board with 
Medicaid. 



In Appendix 7C, the committee provides a more 
detailed discussion of the current Medicaid system- 
-in particular, its eligibility and coverage policies. 
Currently, however, there is ongoing discussion 
and reconsideration of Medicaid, as there is of the 
overall character of health care financing, and it 
would not be sensible therefore to prescribe too 
finely for a system that is meant to emerge 5 to 10 
years from now. Yet these discussions should take 
careful note of the conclusion of the appendix 
discussion: in the committee's judgment, if 
Medicaid is to assume a consistent role across 
the board in financing the public tier of drug 
treatment, federal legislation governing Medic- 
aid must be materially altered so as to address 
drug treatment needs. Such legislation should 
delineate new eligibility criteria, the kinds of 
services and providers eligible for reimburse- 
ment, and minimum reimbursement levels. 

It is clear that adequate drug treatment benefits 
under Medicaid would diminish the need for direct 
service support of drug treatment programs, 
particularly if broader eligibility for Medicaid were 
to emerge for presently ineligible indigent 
populations. Nevertheless, even if completely 
universal insurance coverage were achieved, there 
would still be a need for direct support of public- 
tier programs to offer outreach and other important 
adjunctive services to the many individuals for 
whom low income is not the only barrier to 
seeking and responding well to treatment. 



Transitional Steps Toward the Year 2000 



There are five steps that would be particularly 
useful as incentives toward this transition and 
that would not compromise the efficiency of the 
direct service support mechanism. The first is 
to require all parties to cooperative agreements, 
grants, or contracts involving federal funds to 
develop and display evidence of progress toward 
the long-term goal of increasing the receipt of 
funds from the Medicaid system—for example, 
by facilitating the registration of clients eligible 
for Medicaid benefits and by meeting relevant 
accreditation standards familiar to Medicaid, 
such as those of the Joint Commission on 
Accreditation of Healthcare Organizations or 
the Commission on Accreditation of 



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Rehabilitation Facilities. Those respective 
accreditation organizations, by the same token, 
need to be pressed when developing standards to 
explicitly recognize and incorporate knowledge of 
the public tier of drug treatment providers and 
their procedures. 

The second useful step is to begin stipulating 
matching requirements rather than 
maintenance-of-effort requirements for increases 
in grant support to the states. By determining 
the matching ratio with the same formula used to 
determine Medicaid matching, the incentive to 
states to use Medicaid structures will be increased, 
and the disincentive—having to match every new 
Medicaid dollar but being able to get more block 
grant dollars without increasing state 
appropriations— will be removed. 

The third step is for the federal government to 
require state Medicaid programs to include drug 
treatment as part of the standard package of 
benefits offered to all current (and any newly 
added) Medicaid-eligible persons. The drug 
benefit package should cover methadone treatment, 
outpatient nonmethadone treatment, and residential 
treatment in state-accredited freestanding 
(nonhospital) as well as hospital-affiliated 
residential facilities and outpatient programs. No 
special copayments or limitations— that is, no 
copayments or limits not generally applicable to 
medical/surgical benefits—should be applied to 
drug treatment. 

It is appropriate, however, to impose referral and 
utilization controls to ensure that unrestricted self- 
referral does not lead to the abuse of services. 
These controls, and particularly limitations on 
inpatient services, should conform to those 
described below. For those states with private 
insurance mandates for drug treatment insurance 
coverage, the Medicaid drug treatment benefit 
should be at least as comprehensive as (which does 
not mean identical with) the mandated private 
insurance benefit. 

The fourth step, which applies not only to 
Medicaid but also to the entire range of health 
and human services programs, is to reduce 
gross inconsistencies in the way drug problems 
are handled in eligibility determinations for 
Medicaid, Aid to Families with Dependent 



Children, Medicare, Supplemental Security 
Income, and other income maintenance, 
education, and housing assistance entitlement 
programs. These inconsistencies create a 
bureaucratic nightmare for the drug treatment 
programs and state agencies that draw on more 
than one such source of funds— which most of them 
try to do. The responsible federal agency should 
analyze definitional inconsistencies among federal 
programs and lay out a plan to minimize resulting 
problems. 

The fifth step is to develop a thoroughgoing 
system of public utilization management. Many 
of the components of such a system were 
developed in the SAODAP period but were 
subsequently disestablished. Moreover, a 

substantial portion of the utilization management 
efforts now under way to control costs in the 
alcohol/drug/psychiatric and the general 
medical/surgical benefit areas of Medicare and 
private health insurance are quite similar to the 
controls instituted by SAODAP. 



Utilization Management 

Utilization management describes arrangements to 
define access to effective treatment while keeping 
costs at efficient levels (Gray and Field, 1989). 
Good utilization management works to ensure that 
a fully appropriate and needed range of services is 
used and that different service components are 
coordinated. The most fundamental principles of 
such management are that access to and utilization 
of care should be controlled and managed on a 
case basis by "neutral gatekeepers" or central 
intake personnel (although the central intake 
function may need to be dispersed geographically) . 
These personnel should be regulated by 
certification standards and undergirded by time- 
limited, performance-accounted licenses and 
contracts. 

Client assessment, referral, and monitoring of 
progress in treatment should be reviewed (or 
performed) independently of the treatment 
provider. These personnel should have 

appropriate clinical credentials that include the 
understanding that longer residential and outpatient 
durations are strongly correlated with beneficial 
results among public clients. Effective utilization 



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management should recognize that drug abuse 
and dependence are chronic, relapsing disorders 
and that for any one client, more than one 
treatment episode may be needed and different 
types of treatment may need to be tried. The 
gatekeepers should have access to ongoing 
performance evaluation results and 
responsibility for implementing specific cost- 
control objectives. As with the implementation of 
planning and performance accounting on a large 
scale, the central intake function should focus 
initially on improvement and response and not 
punishment. Yet here, too, the principle of 
coming into line with performance standards must 
apply without much delay. 

There should be rigorous preadmission and 
concurrent review of all residential drug treatment 
admissions, and especially of hospital admissions, 
and concurrent review of outpatient treatment. 
Unlike the objective in utilization management of 
acute hospital care for most medical conditions, 
which is basically to hold inpatient lengths of stay 
to a minimum, the objective for drug treatment 
services should be to increase client retention in 
appropriate, cost-efficient treatment settings. 

The major cost-control concern in this area is the 
use of high-cost treatment when lower cost 
alternatives could be as effective. This hazard 
attaches principally to acute care hospital inpatient 
services for detoxification or rehabilitation 
treatment. Utilization management is a highly 
appropriate way to check this hazard because no 
modality of drug rehabilitation treatment as such 
requires continuous, onsite access to acute care 
hospital services. However, if other criteria (as 
specified below) dictate hospitalization, drug 
treatment may begin in an acute care setting and 
continue elsewhere or shift to more appropriate 
cost rates when acute care requirements end. 

The scientific basis of utilization management of 
drug treatment is at present rudimentary, but 
intake specialists should at least be required to 
demonstrate an understanding of diagnostic criteria 
and effectiveness findings for drug treatment 
programs. A rigid limit on the number or duration 
of treatment episodes permitted to individuals is 
inadvisable; a better method is to employ clinical 
judgment about the client's probability of 
responding positively to treatment. 



The public tier has generally not been heavily 
invested in hospital-based drug treatment, and this 
should continue to be the case— but not as a matter 
of rigid exclusion. The committee recommends 
that hospital-based drug services be reimbursed 
at the same level as nonhospital residential 
treatment rates, unless there is evidence that a 
client specifically requires continuing acute care 
hospital services. Hospital-based drug 

detoxification should only be covered in the 
event of medical complications such as those 
noted below or the lack of appropriate 
residential or outpatient facilities nearby. 
Indications for hospital-based inpatient drug 
detoxification are the following: 

■ serious concurrent medical illness such as 
tuberculosis, pneumonia, or acute hepatitis; 

■ history of medical complications such as 
seizures in previous detoxification episodes; 

■ evidence of suicidal ideation; 

■ dependence on sedative-hypnotic drugs as 
validated by tolerance testing (therapeutic 
challenge) to determine the appropriate 
length of stay; and 

■ history of failure to complete earlier 
ambulatory or residential detoxification 
versus completion in inpatient settings. 

As perhaps the most important and immediately 
needed utilization management requirement, the 
committee recommends that all drug treatment 
programs receiving public support be required 
to participate in a client-oriented data system 
that reports client characteristics, retention, and 
progress indicators at admission, during 
treatment, at discharge, and (on a reasonable 
sampling basis) at one or more follow-up points. 
There should be periodic, independent 
investigation on a sampling basis of the quality and 
accuracy of the data system or systems, and the 
systems should be designed to dovetail with 
ongoing services research and data collection in 
other government agencies and units concerned 
with drug problems. (For example, there should 
be attention to "linkage" questions about numbers 
of arrests and emergency room visits for 
comparability with the Drug Use Forecasting 



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[DUF] and Drug Abuse Warning Network 
[DAWN] systems; see the discussion of research 
needs in Chapter 5.) Certification for public 
support should be time limited and based on 
performance—especially client retention and 
improvement— rather than on process standards. 
Performance is to be demonstrated by outcome 
evaluation, and the standards of performance 
adequacy should be informed by past and ongoing 
treatment effectiveness research on retention and 
outcomes. 

THE SPECIAL CASE OF 
VETERANS' COVERAGE 

The Department of Veterans Affairs represents a 
special case of public coverage. The VA is a 
potential provider of health care for 26.9 million 
surviving veterans of military service— more than 
10 percent of all U.S. citizens. However, its total 
outlay for medical and hospital care in 1988 was 
$10.3 billion, which is less than 2 percent of total 
health expenditures. Although all former military 
personnel are nominally eligible for treatment in 
VA health facilities, all hospital, nursing home, 
and outpatient care provided through the VA is 
now rationed on a priority basis. Of first priority 
are category A veterans (41 percent of the total 
veteran population), those with primarily service- 
related injuries or health problems who are 
receiving VA pensions or who have low incomes. 
Category B veterans (7 percent of veterans) have 
low incomes but no service-connected disabilities. 
Category C veterans (52 percent) have higher 
incomes; they are last in priority and must make 
copayments to receive VA care. In the first year 
(FY 1987) of these standards, 95 percent of 
admissions to VA facilities were from category A; 
only 2 percent each were from categories B or C. 
Although there are 1 1 million veterans eligible for 
VA health services, in FY 1989 only 3.3 million 
of them requested health services of one kind or 
another. 

The VA operates a system of 172 general medical 
facilities that include 56 inpatient drug abuse 
programs, mostly chemical dependency modalities 
but some modified therapeutic communities, and 
66 outpatient drug abuse programs. About one- 
sixth of outpatients in the VA system are on 
methadone maintenance. Although this system is 
accessible (though not always convenient) to most 



veterans for purposes of nonemergency inpatient 
treatment, it entails commutes of several hours or 
more for some veterans, which is not suitable for 
outpatient treatment. (The VA can arrange and 
pay for veterans to be treated in public programs 
under certain circumstances.) 

The VA drug treatment programs delivered 
560,000 inpatient days of care to 17,250 
individuals and 919,000 outpatient visits to 19,800 
individuals in FY 1988. In addition, 18,800 
individuals with primary diagnoses of drug 
dependence received other kinds of inpatient 
treatment in general medical or psychiatric wards, 
and 2,050 received care in nonspecialty outpatient 
clinics. (There is an unknown degree of overlap 
among these populations in different treatment 
settings.) The VA system probably treats more 
individuals than the public tier in any state except 
California or New York. But is this level of 
service high enough? There is reason to think it is 
not. 

Drug problems among veterans have been a 
significant issue for about 20 years. 
Approximately 8.2 million men and women served 
during the Vietnam combat period, of whom 
nearly 40 percent were actually stationed at some 
time in southeast Asia. A study of personnel 
returning from duty in Vietnam in 1973 found that 
43 percent had consumed illicit drugs there. 
Consumption rates declined dramatically, however, 
upon their return home, and only 10 percent 
reported any use in the first six months or more 
after returning; 4 percent reported more-than- 
weekly use for a month or more (Robins et al., 
1974). A more recent study found drug abuse or 
dependence in about 1.5 percent of veterans who 
served during the Vietnam War era, which would 
equal about 125,000 veterans of that era in need of 
drug treatment (Robins, 1974). 

The Treatment Outcome Prospective Study 
(Hubbard et al., 1989) closely examined the 
military experience and discharge status of 1 1 ,200 
clients admitted to drug treatment programs in 10 
major cities during 1979-1981 and found that 14.5 
percent of all admissions were veterans with 
honorable, general, or medical discharges (another 
2.7 percent of admissions had dishonorable 
discharges). Very similar proportions were seen 
across different modalities and in different cities. 



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Even in Philadelphia, which has a major VA 
methadone treatment program that was not 
included in the TOPS sample, eligible veterans 
constituted 15 percent of TOPS methadone 
admissions. Virtually all of these individuals had 
incomes low enough to make them eligible for 
category A or B status under the VA priority 
system. 

Applying the 15 percent proportion to the 640,000 
admissions to public-tier treatment programs in 
1987 suggests that 90,000 to 100,000 admissions 
to these public treatment programs were veterans 
eligible to receive treatment from VA facilities. 
Even if one assumes that the proportion of 
veterans entering drug treatment in the late 1980s 
was substantially less— let us say, one-half or even 
two-thirds less— than the number in 1979-1981 , that 
still totals 30,000 to 45,000 veteran admissions to 
the public tier. It appears very likely that a large 
proportion of eligible category A or B veterans 
were receiving drug treatment outside of the VA 
system, perhaps as many as were treated inside it. 

No study has closely examined whether large 
numbers of veterans are in fact still entering public 
programs instead of VA programs. Neither is it 
clear whether these veterans had attempted 
unsuccessfully to gain admittance to VA treatment 
programs or whether veterans today are 
unsuccessful in gaining admittance. It is only 
strongly suggested by the available data that the 
VA may not be serving a major proportion of 
veterans who are eligible for and need drug 
treatment. In the past several years the VA has 
targeted drug programs for drastic budget 
reductions in order to meet overall fiscal 
limitations. At the very least, outpatient or 
residential drug treatment services— furnished 
directly by VA facilities or by contract— should be 
made available to meet the needs of former 
inpatients. 



CONCLUSIONS 



The committee has developed recommendations 
regarding the public coverage of drug treatment in 
light of some explicit principles that justify public 
coverage, and these principles in turn suggest 
specific priorities for the expansion of the public 



tier that is now under way. The committee 
identified as principles that public coverage should 
seek to reduce external social costs—in particular 
those relating to crime and family role 
dysfunctions— recognizing that this objective often 
requires actively inducing people to seek 
treatment, and that it should remedy constraints 
arising from inadequate income. 

Public coverage should provide adequate support 
for appropriate and timely admission, as well as 
completion or maintenance, of good-quality 
treatment for individuals who cannot pay for it 
(fully or partly) whenever such individuals need 
treatment, according to the best professional 
judgment; whenever they seek treatment; or 
whenever they can be induced through acceptable 
means to pursue it, assuming there is some 
probability of positive response. The committee 
estimates that 35 million individuals qualify as 
indigent with regard to private purchase of any 
form of drug treatment; that is, they are neither 
adequately insured nor able to pay out of pocket 
for appropriate forms of specialized treatment if 
needed and thus would have to rely on public 
services. For residential drug treatment, the 
committee's estimate of those who are unable to 
afford it if needed rises to 60 million. 

The resources needed to achieve the general goal 
of public coverage represent a major increase in 
public support for treatment, and even under the 
current conditions of extraordinary public concern 
about the drug problem and the possibility of 
commensurate appropriations, everything cannot 
be done at once. Priorities for treatment thus need 
to be defined. The committee's recommendations 
on priorities for public-tier expansion are the 
following: 

■ end delays in admission when treatment is 
appropriate, as evidenced by waiting lists; 

■ improve treatment (by raising the levels of 
service intensity, personnel quality and 
experience, and retention rates of existing 
modalities; by having programs assume more 
integrative roles with respect to related 
services; and by instituting systematic 
performance monitoring and follow-up); 



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■ expand treatment through more aggressive 
outreach to pregnant women and young 
mothers; and 

■ further expand community-based and 
institutionally based treatment of criminal 
justice clients. 

It is possible to estimate the amount of new public 
financing needed to meet these priority objectives, 
although to do so, key assumptions must be made 
about such parameters as capital costs, training 
expenses, and the number of individuals who could 
be induced to enter treatment at various levels of 
effort. The committee judges that the amount 
needed to upgrade and expand the drug treatment 
system, beyond current spending rates, is $2.2 
billion in annual operating costs (plus $1.1 billion 
in one-time costs) for a comprehensive plan, $1 
billion annually (plus $0.8 billion up front) for a 
core plan, or $1.6 billion annually (plus $0.5 
billion in up-front costs) for an intermediate plan. 
Because the data supporting the costs of the 
recommended strategies are uncertain, it is 
essential that relevant data collection be developed 
very quickly and its products analyzed as soon as 
possible. 

The committee's recommended strategies lead to a 
consideration of needed changes in how to manage 
the public tier. These issues divide into the 
following: the roles and interrelations of the 
states, the federal government, and public-tier 
providers; the most appropriate shorter and longer 
term financing mechanisms for providing public 
support (direct service programs versus public 
insurance); and the controls needed to make the 
most effective and efficient use of public funds. 

State governments have played the major role in 
financial administration and quality control of drug 
treatment programs in recent years, but there has 
also been cyclical movement between state and 
federal leadership. The federal government 
originally built most of the public tier of providers 
and then transferred responsibility for regulating 
and supporting this tier largely to the states; it is 
now moving back into the lead role. This 
expansion of federal support should be 
accompanied by more active, centralized direction 
and control of treatment resources. At present, 
both direct service grants or contracts and 



reimbursement through Medicaid (and similar 
programs) play some part in supporting the public 
tier. Direct program support is much larger and 
will continue to grow as the federal grant and 
demonstration programs expand. Emphasis on 
direct service is an appropriate model for directed 
system building, but long-term system maintenance 
may be better served by a proportionately greater 
use of public insurance financing supplemented by 
direct service grants to ensure critical program 
elements such as outreach and integration with 
nonhealth services. The ground should be 
prepared to "mainstream" drug treatment more 
fully, incorporating it into public health care 
financing for the poor, that is, Medicaid. 

Under either support mechanism, the protection 
and stimulation of program quality, efficient 
operation, and appropriate utilization are crucial. 
Utilization criteria and regular outcome analysis 
should be more generally deployed in drug 
treatment systems. Central intake functions based 
on clear clinical criteria, performance 
measurement and contracting, and outcome 
analysis are critical components of a system of 
treatment performance disciplined by information 
and incentives. 

In the special case of drug treatment for low- 
income veterans, enough evidence has accumulated 
to provoke concerns that the VA may not be 
providing an adequate range of services. There is 
probably a need to expand VA outpatient drug 
treatment programs, and the adequacy of the VA 
residential system needs comprehensive evaluation. 



APPENDIX 7A 

BASELINE AND STRATEGY OPTION 

CALCULATIONS 



Baseline Comparison Values 

All cost estimates for the committee's three 
strategy options are based on the most recent data 



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available at the end of 1989 concerning the size 
and financing of the public treatment system. 
According to the National Drug and Alcohol 
Treatment Utilization Survey compiled in late 1987 
and early 1988 (see Chapter 6), the public tier of 
community-based drug treatment providers treated 
at least 636,000 clients during 1987, had 212,000 
individuals enrolled in treatment in October 1987, 
and had annual revenues of $800 million. This 
tier includes a very small proportion (less then 10 
percent) of privately reimbursed clients and 
revenues. (In addition, a very small number of 
publicly financed clients were treated by private- 
tier providers.) 

These baseline values are biased downward 
somewhat because the 1987 survey was incomplete 
(some providers did not respond at all or 
responded only partially) and resources and clients 
increased between 1987 and 1989. In a number of 
the projection components of the strategy options 
(e.g., costs of training, renovations, expansion of 
treatment facilities), 1987 baseline values are used 
for estimation. To the extent that these values are 
below the actual 1989 values, the committee's 
projections underestimate future resource 
requirements. 

The committee imputed a provisional set of 1989 
estimates for the public tier of providers, pegging 
expenditures at $1.1 billion, the number of clients 
currently in treatment at 275,000, and the number 
of clients treated during the past year at 815,000. 
The imputation is based on partial information 
about increases in funding and clients served. 
Expenditures in public-tier treatment in 1989 were 
at least $1.1 billion, based on extrapolating the 17 
percent annual increases in public drug plus 
alcohol treatment funding reported by state drug 
and alcohol agencies between 1985 and 1988 
(Butynski and Canova, 1989, and prior years). 
According to the same source, the number of drug 
clients treated increased by about 20 percent 
annually; these authors, however, attribute an 
unknown proportion of this increase to 
improvements in the comprehensiveness of state 
data systems (for example, including clients treated 
in community mental health centers). The 
committee therefore has imputed a 13.3 percent 
annual client increase (two-thirds of the apparent 
annual change, allowing for a small inflation 
adjustment). 



CORE STRATEGY OPTION 



Annual Recurring Costs 



Eliminate waiting lists 

Increase daily treatment enrollment by 66,000 
(survey of 43 states in September 1989 by 
NASADAD shows minimum need of 66,000 
slots) . 

Fund at new rate per client in treatment— 
$5,000 per client in treatment, or $1,860 per 
client treated (based on increased resources 
per client and retention). 

Keep current mix of residential and outpatient 
treatment. 

66,000 x $5,000 = $330 million 



Restore funding per client to 1976-1979 level 

Increase reimbursements per client by 25 % . 
Expect client retention to increase by 10%; 
therefore, admit same number of clients per 
year, with current census increasing by 10%. 

Keep current mix of residential and outpatient 
treatment. 



($1.1 billion x 1.25 x 1.10) 
= $412.5 million 



$1.1 billion 



Staff training 

Assume minimum of 26,000 staff in 1989. 

Assume 39,200 total staff in future, which 
equals 26,000 staff in 1989 divided by 
275,000 clients in 1989 times 377,900 clients 
in future times 1.1 for increase in staffing 
intensity. 



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Assume annual training expense of $500 per 
staff person (average 5 days/year at $100 per 
day). 

26,000 x $500 = $13 million, first year 
39,200 x $500 = $19.6 million, 
subsequent years 



Pro gram/ client performance monitoring system 

Assume 815,000 annual public-tier clients in 
1989. 



Treat 18,750 expectant mothers 

Assume half of recruited expectant mothers 
participate in 6 months of therapeutic 
community treatment ($12,500 per year plus 
25% increase), and half get 6 months of 
outpatient treatment ($2,500 per year plus 
25% increase; costs documented in Chapter 
6). 

[9,375 x ($12,500 x 1.25) / 2] + [9,375 x 
($2,500 x 1.25) / 2] = $87.9 million 



Core scenario treats 196,600 more clients 
annually. 

Estimate $25 per client for client reporting at 
intake, during treatment, and at discharge. 

Assume postdischarge follow-up performed 
on 25% of public clients. 

Estimate $200 per client tracked and 
interviewed to perform follow-up assessment 
after discharge. 

(815,000 + 196,600) x [$25 + (0.25 x 
$200)] = $75.9 million 



Active outreach to expectant mothers 

Assume active outreach to drug-using 
expectant mothers reaches 18,750 at a cost 
of $1 ,000 each (about the cost per expectant 
mother reached in a demonstration outreach 
in Harlem, NY, cited in Institute of 
Medicine report on neonatal care [Brown, 
1988]). 

18,750 x $1,000 = $18.8 million 



Children of mothers in residential programs 

Assume 25% of the 28,600 public residential 
clients are female (Institute of Medicine 
analysis of 1987 NDATUS). 

Assume residential treatment given to 10.6% 
of waiting list (same as the proportion of 
1987 NDATUS public clients in residential 
programs) but only 25% of those entering 
will be female. 

Of 18,750 additional expectant mothers 
treated per year, half get residential care of 
average 6 months. 

Assume 22.5% of women have one or more 
children, and these average 2.5 children each 
(communication from R.L. Hubbard, special 
analysis of TOPS data). 



Assume domiciliary child care costs of $500 
per child/month, or twice the cost of 
inexpensive day care ($6,000/year). 

[(28,600 x 1/4) -I- (66,000x0.106) x 1/4) + 
(18,750 x 1/2 x 1/2)] x 0.225 x 2.5 x $6,000 
= $45.9 million 



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One-time Capacity Expansion/Improvements 



Residential capacity expansion 

Increased length of stay requires additional 
2,250 beds. 

Waiting list expansion requires 7,000 beds. 

Expectant mothers expansion requires 4,688 
beds. 

Assume construction cost of $20,000 per 
client space (from Donald McConnell, 
executive director of the State of Connecticut 
Alcohol and Drug Commission; alternative 
estimate of $26,000 per client space from 
David Mactas, president of Marathon House 
in Rhode Island). 

(2,250 + 7,000 + 4,690) x $20,000 = 
$278.8 million 

Repair existing residential facilities 

Assume cost of repairing space in use is 
20% of cost of building (0.20 x $20,000 = 
$4,000 per bed). 

Assume 22,500 public-tier residential beds in 
use in 1987. 

22,500 x $4,000 = $90 million 



Repair existing outpatient facilities 

Assume 189,000 enrolled in public-tier 
programs. 

Assume repair costs of 20% of upgraded 
annual cost, which equals $2,500 per client 
year times 1.25, or $3,125. 

189,000 x 0.20 x $3,125 = $118.1 million 



Train additional staff 

Assume minimum of 26,000 staff in 1989. 

Assume requirement for 13,300 additional 
staff, which equals 26,000 staff in 1989 
divided by 275,000 clients in 1989 times 
377,900 clients in future times 1.1 for 
increase in staffing intensity. 

Assume $2,000 per additional staff for first 
10,000 (assumes most with some prior 
experience or related training in drug 
problems) and $4,000 per each additional 
staff (minimal or no closely related 
experience or training). 

10,000 x $2,000 + 3,300 x $4,000 = 
$33.2 million 



COMPREHENSIVE STRATEGY OPTION 
Annual Recurring Costs 

Eliminate waiting list 

Same as under core option. $330 million 

Restore funding per client to 1976-1979 level 
Same as under core option. $412.5 million 

Staff training 

Assume minimum of 26,000 staff in 1989. 

Expect 60,200 total staff in future, which 
equals 26,000 staff in 1989 divided by 
275,000 clients in 1989 times 578,600 clients 
in future times 1.1 for increase in staffing 
intensity. 



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Assume annual training expense of $500 per 
staff. 

26,000 x $500 = $13 million, first year 
60,200 x $500 = $30.1 million, 
subsequent years 



Program/client performance monitoring system 

Assume 815,000 annual public-tier clients in 
1989. 



Treat 56,250 expectant mothers 

Assume half of recruited expectant mothers 
participate in 6 months of therapeutic 
community treatment (currently $12,500 per 
year, funding upgraded by 25%), and half get 
6 months of outpatient treatment (currently 
$2,500 per year, funding upgraded by 25%). 

(28,125 x $12,500 x 1.25 + 28,125 x $2,500 
x 1 .25) / 2 = $263.7 million 



Compromise scenario treats 689,600 more 
clients annually. 

Estimate $25 per client for client reporting at 
intake, during treatment, and at discharge. 

Assume postdischarge follow-up performed 
on 25% of public clients. 



Children of mothers in residential programs 

Same as under core option except 56,250 
expectant mothers treated per year. 

[(28,600 x 1/4) + (66,000 x 1/4 x 0.106) + 
(56,250 x 1/2 x 1/2)] x 0.225 x 2.5 x $6,000 
= $77.5 million 



Estimate $200 per client tracked and 
interviewed to perform follow-up assessment 
after discharge. 

(815,000 + 689,600) x [$25 + (0.25 x 
$200)] = $112.8 million 



Comprehensive probation emphasis on treatment 

Increase daily treatment enrollment of 
probationers or parolees by 132,000 (double 
the waiting list number). 



Aggressive outreach to expectant mothers 

Assume aggressive outreach to drug-using 
expectant mothers reaches 15% with 
increasing cost per expectant mother reached 
(18,750 reached at $1,000 each plus 18,750 
reached at $2,000 each plus 18,375 reached 
at $3,000). 



Fund at new rate per client in treatment— 
$5,000 per client in treatment, or $1,860 per 
client treated. 

Keep current mix of residential and outpatient 
treatment. 

132,000 x $5,000 = $660 million 



18,750 x $1,000 + 18,750 x $2,000 + 
18,750 x $3,000 = $112.5 million 



Comprehensive prison treatment 

Increase daily prison treatment enrollment by 
50,000, or twice the compromise goal 
(average treatment retention, 6 months). 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 7 

Assume $3,125 per treatment year delivered 
in prison. 

50,000 x $3,125 / 2 = $156.3 million 
One-time Capacity Expansion/Improvements 



Residential capacity expansion 

Increased length of stay requires additional 
2,250 beds. 

Waiting list expansion of 25% requires 
7,000 beds. 

Criminal justice system expansion also adds 
50% (14,000 beds). 

Expectant mothers expansion requires 14,060 
beds. 

Assume cost of $20,000 per additional space 
(discussed above) . 

(2,250 + 7,000 + 14,000 + 14,060) x 
$20,000 = $746.2 million 



Repair existing residential facilities 

Same as under core option. $90 million 

Repair existing outpatient facilities 

Same as under core option. $118.1 million 

Train additional staff 

Assume minimum of 26,000 staff in 1989. 

Assume requirement for 34,200 additional 
staff, which equals 26,000 staff in 1989 



divided by 275,000 clients in 1989 times 
578,600 clients in future times 1.1 for 
increase in staffing intensity. 

Assume $2,000 per additional staff for first 
10,000 (assumes most with some prior 
experience or related training in drug 
problems) and $4,000 per each additional 
staff (minimal or no closely related 
experience or training). 

10,000 x $2,000 + 24,200 x $4,000 = 
$116.8 million 



INTERMEDIATE STRATEGY OPTION 
Annual Recurring Costs 

Eliminate waiting list 

Same as under core option. $330 million 

Restore funding per client to 1976-1979 level 
Same as under core option. $412.5 million 

Staff training 

Assume minimum of 26,000 staff in 1989. 

Expect 49,800 total staff in future, which 
equals 26,000 staff in 1989 divided by 
275,000 clients in 1989 times 478,300 clients 
in future times 1.1 for increase in staffing 
intensity. 

Assume annual training expense of $500 per 
staff. 



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26,000 x $500 = $13 million, first year 
49,800 x $500 = $24.9 million, 
subsequent years 

Program/client performance monitoring system 

Assume 815,000 annual public-tier clients in 
1989. 

Compromise scenario treats 443,100 more 
clients annually. 

Estimate $25 per client for client reporting at 
intake, during treatment, and at discharge. 

Assume postdischarge follow-up performed 
on 25% of public clients. 

Estimate $200 per client tracked and 
interviewed to perform follow-up assessment 
after discharge. 

(815,000 + 443,100) x [$25 + (0.25 x 
$200)] = $94.4 million 



Aggressive outreach to expectant mothers 

Assume aggressive outreach to drug-using 
expectant mothers reaches 18,750 at $1,000 
each plus 18,750 additional at $2,000 each. 

18,750 x $1,000 + 18,750 x $2,000 = 
$56.3 million 



Treat 37,500 expectant mothers 

Assume half of recruited expectant mothers 
participate in 6 months of therapeutic 
community treatment (currently $12,500 per 
year, funding upgraded by 25%), and half 
get 6 months of outpatient treatment 
(currently $2,500 per year, funding upgraded 
by 25%). 



(18,750 x $12,500x1.25 + 18,750 x $2,500 
x 1.25)/ 2 = $175.8 million 



Children of mothers in residential programs 

Same as under core option except 37,500 
expectant mothers treated per year. 

[(28,600 x 1/4) + (66,000 x 1/4 x 0.106) + 
(37,500 x 1/2 x 1/2)] x 0.225 x 2.5 x $6,000 
- $61.7 million 



Modest probation/parole induction 

Increase daily treatment enrollment of 
probationers or parolees by 66,000 (equal to 
prior increase to admit waiting list). 

Fund at new rate per client in treatment— 
$5,000 per client in treatment, or $1,860 per 
client treated. 

Keep current mix of residential and outpatient 
treatment. 

66,000 x $5,000 = $330 million 



Modest prison treatment 

Increase daily prison treatment enrollment by 
25,000. 

Fund at $3,125 per treatment year delivered 
in prison (assumed as equal to annual funding 
of outpatient because residential costs are 
already covered by prison). 

25,000 x $3,125 = $78.1 million 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 7 



One-time Capacity Expansion/Improvements 



Residential capacity expansion 

Increased length of stay requires additional 
2,250 beds. 

Waiting list expansion of 25% requires 
7,000 beds. 

Criminal justice system expansion also adds 
25% (7,000 beds). 

Expectant mothers expansion requires 9,375 
beds. 

Assume annual cost of $20,000 (see core 
estimates). 

(2,250 + 7,000 + 7,000 + 9,375) x 
$20,000 = $512.5 million 



Repair existing residential facilities 

Same as under core option. $90 million 

Repair existing outpatient facilities 

Same as under core option. $118.1 million 

Train additional staff 

Assume minimum of 26,000 staff in 1989. 

Assume requirement for 23,750 additional 
staff, which equals 26,000 staff in 1989 
divided by 275,000 clients in 1989 times 
478,300 clients in future times 1.1 for 
increase in staffing intensity. 

Assume $2,000 per additional staff for first 
10,000 (assumes most with some prior 



experience or related training in drug 
problems) and $4,000 per each additional 
staff (minimal or no closely related 
experience or training). 

10,000 x $2,000 + 13,750 x $4,000 = 
$75 million 



APPENDIX 7B 

MODELING FUTURE TREATMENT NEEDS 

AND EFFECTS 



All of the strategy options presented here involve 
prospective resource requirements and 
expenditures over the next three to five years. 
How long such needs will last is a very important 
question, but unfortunately there is no solid base 
on which to ground the answer. The goal of early 
aggressive initiatives is obviously to reduce current 
and future problems and requirements for drug 
treatment and enforcement expenditures in the 
future. 

Although there is evidence that drug treatment 
reduces the treated individual's likelihood of future 
drug use and criminal activity, this evidence must 
be incorporated into a systematic epidemiological 
model of drug consumption across the population, 
considering factors that affect onset, progression, 
duration, recovery, and relapse, as well as the 
respective effects of prevention, enforcement, and 
treatment. A dynamic model is required that 
predicts the potential need for treatment services 
over time contingent on alternative public policies. 
One might hypothesize that a "status quo" policy 
of limited availability of treatment with current 
prevention and enforcement policies would 
produce a gradually increasing need for treatment. 
"Legalization" of currently illicit drugs could 
result in dramatic increases in the clinically 
defined need for treatment (although legalization 
proponents contend this tendency to increase need 



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PUBLIC COVERAGE 



would be offset in terms of economic costs and 
perhaps clinical criteria as well by reduced 
criminal activity). Intermediate anti-drug policies 
(treatment, prevention, and enforcement) could be 
expected to progressively reduce the need for 
treatment over time relative to the status quo of 
limited treatment availability. The alternative 
scenarios represent fears and desires regarding the 
effectiveness of drug policy; what is required is 
sophisticated analysis and modeling of the effects 
of different anti-drug policies on the number of 
drug users, their legal and criminal behaviors, and 
their need for treatment. 

Although rudimentary dynamic models of heroin 
and cocaine use have been developed (Levin et al., 
1975; Hunt and Chambers, 1976; Gardiner and 
Schreckengost, 1987; Homer et al., 1988), no one 
has yet produced a model that incorporates all 
drugs or simulates the effects of public policy 
variables (prevention, treatment, and enforcement). 
Consequently, the strategy options described 
earlier in this chapter must be considered short- to 
medium-term estimates, and judgments about more 
distant future requirements must be left in 
abeyance at present. 



APPENDIX 7C 
MEDICAID 



Although the ADMS block grant has been the 
principal federal mechanism to support the public 
drug treatment system during the 1980s, the public 
health insurance plans, Medicaid and Medicare, 
have devoted a notable amount of resources and 
attention to drug treatment in recent years. 
Coverage by Medicaid is the major alternative to 
grant and contract mechanisms as the way to 
provide public coverage. 



Medicaid is the major mechanism of public health 
care financing for low-income people in the United 
States who by and large cannot afford individual 
private health policies and do not hold jobs that 
include employer-sponsored group plan coverage— 
with the obvious exception of the large group of 
people with low incomes who receive their 
primary health coverage from Medicare. 5 The 
Medicare population of 32 million is mostly over 
65 years of age and is relatively peripheral with 
regard to the kinds of drug problems that most 
engage public concern. Therefore, Medicare is 
not a key element in considering public-tier 
funding. 6 

A few states now use Medicaid on a fairly 
extensive basis to support drug treatment services, 
and it has some role in nearly all states. Enough 
states increased their use of Medicaid during the 
1980s that, according to the NDATUS results, 
from 1982 to 1987 public third-party 
reimbursements (which are primarily Medicaid) 
more than doubled. Yet despite the significant use 
of Medicaid in a few states, there are powerful 
limitations on what it now can and cannot do for 
the population without private insurance. To see 
why, it is necessary to review briefly the way 
Medicaid coverage policy is determined and its 
limitations with respect to eligibility and services. 



6 ln addition, certain large populations depend on health 
programs of the Departments of Veterans Affairs and the 
Department of Defense (DoD) for access to drug treatment. 
Generally, the committee has not considered populations 
covered by the specialized programs of DoD-military personnel 
and dependents— as part of this study, except insofar as VA 
programs were discussed earlier in this chapter. 

"To put the point more concretely, illicit drug abuse and 
dependence are not major cost factors in Medicare, nor do 
Medicare clients figure prominently in the financing of drug 
treatment programs. In 1983, for example, there were 4,451 
general hospital admissions of Medicare clients with a primary 
diagnosis of drug dependence or abuse~O.04 percent of the 1 
million annual Medicare hospital admissions. (By comparison, 
there were 53,019 Medicare admissions with a primary 
diagnosis of alcoholism [Harwood et al., 1985].) In 1987, drug 
treatment programs of all modalities reporting to states 
admitted only 1 ,300 clients aged 65 and older (Butynski and 
Canova, 1988). 



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Coverage Policy Determination Under Medicaid 

Medicaid is a cooperative federal/state program 
regulated by federal law but administered by state 
officials; under it the states have a great deal of 
autonomy, including the simple option not to 
participate. The federal government pays half or 
more of the costs of Medicaid program claims in 
a state on a matching formula basis, with the 
match coming from state appropriations. The 
match varies from 1:1 to 3:1 (federal: state funds), 
depending on a mathematical formula that is set 
for each state based on its poverty and income 
characteristics. The federal government sets 
certain minimum requirements (in terms of whom 
a state must consider eligible and what services 
and procedures its program must cover) for 
classification as a "participating state," that is, to 
receive federal matching dollars. 

Beyond these minima, states have substantial 
options to cover more people or services on their 
own, and the federal government will continue to 
match these expenditures on the same basis as the 
required coverage. Federal regulations permit 
reimbursement of most services delivered in the 
major drug treatment modalities, but they do not 
require states to cover most of them. As a result, 
there is no consistency across states in who gets 
covered for drug treatment or in what kinds of 
drug treatment services are reimbursed. 

In 1987 the NDATUS found that third-party public 
payments to reporting providers were $139 
million, or nearly 11 percent of total reported 
revenues (Table 7C-1). Third-party public 
reimbursements included Medicaid, Medicare, and 
some payments by insurance programs for military 
families using nonmilitary treatment services. It is 
probable that most of the reported revenues were 
Medicaid dollars, among other reasons because the 
majority of these reimbursements were in just 
three states that make significant use of Medicaid 
for drug treatment: New York, California, and 
Pennsylvania, which accounted for nearly $90 
million out of the $139 million in revenues. 



(These states have quite different approaches, 
however, and the large dollar flow in California is 
attributable to that state's large size rather than to 
an unusual level of commitment to this financing 
mechanism.) Without more detailed information, 
which no one has yet assembled, it is impossible to 
know to what extent different factors account for 
the very large differences in state coverage, factors 
such as eligibility requirements, the nature of 
services covered, the reimbursement rates 
established by the different states, underlying 
needs for treatment, and adequacy of alternative 
financing mechanisms. 



Eligibility 



The Medicaid system was the primary health 
insurance protection during some part of 1986 for 
20.6 million citizens under the age of 65 (Chollet, 
1988; U.S. Department of Commerce, 1988); in 
comparison, 32.4 million persons in this age group 
were estimated to be living in poverty (U.S. 
Department of Commerce, 1988). The reason for 
this evident gap is that, although federal 
requirements hold that certain disadvantaged 
persons and family configurations are categorically 
qualified for Medicaid coverage, the states still 
have enormous discretion in setting the income- 
based standards for eligibility within these 
categories. 

All state plans must cover individuals who qualify 
for Supplemental Security Income, which includes 
blind, permanently and totally disabled, and aged 
(over 65) individuals with low annual incomes and 
total assets. These standards qualified 6.3 million 
persons in 1986, of whom 3.1 million each were 
aged and disabled, for reimbursement by Medicaid 
of services not covered by Medicare. Probably the 
major significance of this population's eligibility is 
that Medicare will not pay for nursing home care 
but Medicaid will, and nursing home claims now 
account for more than two-thirds of all Medicaid 



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payments, limiting the capacity of this system to 
deal with other kinds of health problems. 

Most Medicaid beneficiaries (15.5 million) are 
eligible for Medicaid assistance owing to their 
receipt of Aid to Families with Dependent 
Children (APDC), which is another federal/state 
cooperative program. AFDC eligibility is based 
on a categorical qualification plus an income 
standard established by the individual states. It 
always covers single-parent families, pregnant 
women, and young children in two-parent families 
provided their household of residence has an 
income below a financial "standard of need" that 
is usually configured in terms of a percentage of 
the federal poverty line. States may at their option 
cover as "medically needy" categorically eligible 
persons in households with incomes somewhat 
above the AFDC standard (that is, individuals who 
cannot receive AFDC). But most states have used 
their great latitude in establishing the standard of 
need to set the income level of AFDC eligibility, 
and thus Medicaid eligibility, at a percentage 
somewhat if not substantially (e.g., 35 percent) 
below the poverty line. 

The federal statutes for Medicaid allow states the 
option of covering certain additional individuals 
who do not fit the mandatory categories: older 
children, two-parent intact families, single adults, 
and childless couples. Very few states have taken 
up these options, which would bring Medicaid 
much closer to being a form of universal coverage 
for low-income people. As a result, probably the 
largest segment of drug-abusing and dependent 
individuals— young, single adult males— are 
categorically ineligible for Medicaid. 

Aside from eligibility as such, actual registration 
for Medicaid can be a problem. In New York, 
where Medicaid standards are relatively inclusive, 
drug treatment programs routinely check whether 
new clients are certified or prima facie eligible for 
public assistance, which virtually ensures Medicaid 
eligibility. Uncertified but eligible clients may 
complete application forms (kept handy by 



admission units) at the time of initial program 
contact and submit them by mail. In contrast, 
application for Medicaid coverage in most states 
must be made in person at a central office. 



Coverage Provisions 

The federal guidelines for minimum benefits do 
not specifically deal with drug treatment. 
Federally required Medicaid services primarily 
include inpatient and outpatient hospital services 
and physician services. Although these services 
are sometimes necessary to treat some kinds of 
drug problems and to deal with such sequelae or 
complications as trauma, AIDS, and other 
infectious diseases, the primary components of 
drug abuse treatment are psychosocial services 
(counseling, social work, psychotherapy), 
pharmacotherapy (medications such as methadone, 
buprenorphine, or desipramine), and residency in 
a therapeutic milieu. Coverage for counseling 
services, prescribed medications, and residential 
treatment outside of hospital wards is not required 
but is left to the discretion of the states, along with 
the rates at which these elements are reimbursable. 

There is no systematic study available of state 
Medicaid coverage for specific drug treatment 
services. A number of states do reimburse 
selected types and amounts of relevant services, 
most commonly (based on the committee's site 
visit information), physician examinations at 
admission (but generally at a rate equal to a 
conventional outpatient office visit rather than a 
multiphasic examination appropriate for an 
individual potentially severely compromised by 
drug abuse or dependence), methadone 
prescription (but generally at a rate that does not 
cover the cost of meeting federal regulations to run 
a lawful maintenance clinic), and services of 
psychiatrists or licensed clinical psychologists (but 
not other counseling professionals). Emergency 
hospitalization for drug overdoses is generally 
covered, but treatment in residential programs is 
rarely reimbursed. 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1. CHAPTER 7 

These selective reimbursements have been 
sufficient to allow a few states with relatively wide 
eligibility and generous benefits, such as New 
York, Pennsylvania, and Colorado, to draw on 
Medicaid as the source of more than 20 percent of 
all provider revenues. (In New York, moreover, 
public assistance-eligible clients in residential 
programs may also receive reimbursement under 
the Home Relief and Food Stamps programs, 
which helps to defray residential program 
expenses.) In many other states, however, drug 
treatment providers receive almost no Medicaid 
support. 



The Current and Future Status 
of Medicaid Coverage 

In theory, the Medicaid system could cover many 
drug-abusing and dependent individuals because 
the clients served by the public tier are mostly 
indigent and that population is the group Medicaid 
was designed to serve. Yet the future role of 
Medicaid is undefined. In a few states, it is an 
important underpinning of the treatment system; in 
others, its effect is negligible. In the committee's 
judgment, if Medicaid is to assume a consistent 
role across the board in financing the public tier 
of drug treatment, federal legislation governing 
Medicaid must be materially altered so as to 
address drug treatment needs. Such legislation 
should delineate eligibility criteria, the kinds of 
services and providers eligible for 
reimbursement, and minimum reimbursement 
levels. 

There are interesting precedents for Medicaid 
financing of drug treatment. The AIDS crisis is 
leading to new federal and state initiatives that 
extend Medicaid coverage to populations not 
previously included. In California, individuals 
diagnosed with AIDS or AIDS-related complex are 
categorically eligible for Medicaid coverage, 
whether or not they are eligible under other 
categories. If they qualify in terms of the income 
criterion, these individuals may receive Medicaid 



reimbursement for covered hospital and physician 
services. 

In a related precedent, many states are using their 
Medicaid systems to disburse $30 million in 
federal formula grant funds for purchase of the 
prescribed AIDS medication AZT. These one-time 
emergency grants had no federal attachment to 
Medicaid, but many states have found it efficient 
and convenient to use their existing Medicaid 
billing, administrative, and disbursement systems 
to spend and document these funds, even though 
the medication is purchased largely by individuals 
who are not otherwise categorically eligible or are 
not recipients of Medicaid coverage. This 
experience demonstrates that existing Medicaid 
reimbursement mechanisms can be adapted to 
manage other reimbursements that are parallel to 
but not part of Medicaid under present state 
criteria. 

Finally, and most pertinently, recent legislation 
(P.L. 100-360) requires states to provide Medicaid 
coverage to pregnant women and their infants who 
meet or exceed the federal poverty level by up to 
35 percent. This provision is limited to health 
services related to pregnancy and to conditions that 
threaten the well-being of the infant. Maternal 
drug abuse certainly threatens the health of the 
infant, but whether this provision leads to the 
induction of such women into appropriate forms of 
care remains to be seen. The committee's 
recommendations regarding expanded outreach to 
this population could be partially— and increasingly 
over time— supported through Medicaid 
reimbursement for those eligible. 



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TABLE 7C-1 Third-Party Public Revenues by State in 1987 as a Percentage of Public State Total 
Revenues and of National Third-Party Public Payments 





State Revenues 


Third-Party Public Payments 




Third-Party 

($000s) 


Total 


Percentage of 
State Total 


Percentage of 


State 


($000s) 


All National 


Alabama 


644 


6,987 


9.2 


0.5 


Alaska 


16 


3,366 


0.5 


0.0 


Arizona 


948 


24,328 


3.9 


0.7 


Arkansas 


354 


2,641 


13.4 


0.3 


California 


17,779 


256,530 


6.9 


12.8 


Colorado 


3,753 


18,458 


20.3 


2.7 


Connecticut 


1,797 


20,832 


8.6 


1.3 


Delaware 


5 


1,352 


0.4 


0.0 


District of Columbia 


17 


7,306 


0.2 


0.0 


Florida 


2,446 


61,729 


4.0 


1.8 


Georgia 


478 


24,288 


2.0 


0.3 


Hawaii 


22 


4,730 


0.5 


0.0 


Idaho 


5 


1,429 


0.3 


0.0 


Illinois 


1,227 


40,484 


3.0 


0.9 


Indiana 


1,092 


17,391 


6.3 


0.8 


Iowa 


1,118 


11,553 


9.7 


0.8 


Kansas 


498 


6,443 


7.7 


0.4 


Kentucky 


1,161 


7,745 


15.0 


0.8 


Louisiana 


1,880 


13,967 


13.5 


1.4 


Maine 


245 


3,459 


7.1 


0.2 


Maryland 


3,031 


27,837 


10.9 


2.2 


Massachusetts 


642 


20,300 


3.2 


0.5 


Michigan 


1,613 


36,408 


4.4 


1.2 


Minnesota 


2,337 


25,772 


9.1 


1.7 


Mississippi 


115 


1,769 


6.5 


0.1 


Missouri 


500 


15,103 


3.3 


0.4 


Montana 


9 


1,786 


0.5 


0.0 


Nebraska 


146 


4,725 


3.1 


0.1 


Nevada 


21 


2,971 


0.7 


0.0 


New Hampshire 


196 


5,637 


3.5 


0.1 


New Jersey 


788 


32,797 


2.4 


0.6 


New Mexico 


610 


6,363 


9.6 


0.4 


New York 


58,773 


250,382 


23.5 


42.2 


North Carolina 


1,337 


18,848 


7.1 


1.0 


North Dakota 


725 


6,486 


11.2 


0.5 


Ohio 


6,209 


59,123 


10.5 


4.5 


Oklahoma 


527 


8,227 


6.4 


0.4 


Oregon 


223 


10,918 


2.0 


0.2 


Pennsylvania 


14,190 


69,845 


20.3 


10.2 


Puerto Rico 





10,217 


0.0 


0.0 


Rhode Island 


28 


5,115 


0.5 


0.0 


South Carolina 


431 


7,263 


5.9 


0.3 


South Dakota 





778 


0.0 


0.0 


Tennessee 


1,016 


9,279 


10.9 


0.7 


Texas 


4,859 


64,341 


7.5 


3.5 


Utah 


220 


6,828 


3.2 


0.2 


Vermont 


73 


917 


8.0 


0.1 


Virginia 


1,531 


28,653 


5.3 


1.1 


Washington 


1,275 


11,474 


11.1 


0.9 


West Virginia 


249 


2.941 


8.5 


0.2 


Wisconsin 


2,023 


18,200 


11.1 


1.5 


Wyoming 


48 


1,762 


2.7 


0.0 


Total United States 


139,227 


1,308,013 


10.6* 


100.0 


Source: IOM analysis of the 1987 National Drug and Alcoholism Treatment Utilization Survey. 'This figure is an 


average rather than a sum. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



213 



CHAPTER 8: PRIVATE COVERAGE 



Although the public tier admits the great majority 
of drug-abusing and drug-dependent individuals 
who receive treatment each year and their 
treatment is paid for mainly with public funds, 
there is a private tier of treatment providers as 
well that serves a significant proportion of the 
individuals seeking treatment and that uses an even 
larger proportion of treatment funding. Most of 
the support for the private tier depends on 
insurance reimbursements, and most private health 
insurance in the United States is obtained through 
employer-sponsored health insurance plans. 
Moreover, most if not all of the premium is 
treated as a fringe benefit rather than a part of 
wages or salaries. As a result, health insurance 
purchases are constrained in ways that purchases 
of other consumer goods, such as food, cars, or 
housing, are not. 

Employers, whether private firms or public 
agencies, are the primary payers on behalf of their 
employees and immediate families. Consequently, 
employers have a major influence on and financial 
responsibility for the extent and nature of 
insurance coverage for drug treatment. This 
influence is especially felt when the benefit 
package is not developed by collective bargaining 
agreements, which give workers greater leverage 
over the terms of coverage. Although employer- 
sponsored health insurance was developed 
originally in bargained (that is, union-management) 
contracts, most employees are not represented by 
unions. This chapter therefore considers the 
provision of coverage largely from the perspective 
of employers vis-a-vis employees and insurers. 

The chapter first discusses the logic of private 
coverage by health insurance and out-of-pocket 
payments. In Chapter 7 the committee estimated 
the number of individuals who would probably 
need to rely on the public system for coverage in 
the event they sought drug treatment. Here, the 
discussion simply reviews the principle that 
treatment effectiveness, cost, and the price 
sensitivity of potential consumers of treatment 



jointly contribute to determining the socially 
optimal level of private coverage. 

The next issue is the actual extent of private 
coverage. There are data to respond to this 
question, but they are less than satisfactory. The 
first source of information is ostensible coverage, 
that is, the written details of health insurance 
policies or comparable health plan benefits. 
Surveys of coverage provisions, however, are 
generally limited to medium- and large-scale 
employers. Moreover, this information, although 
useful, is of uncertain application because actual 
coverage may vary under the same ostensible 
provisions. The usual survey practice is to index 
coverage according to whether drug treatment 
benefits are explicitly defined. But the written 
provisions may understate that coverage if the plan 
implicitly considers drug dependence to be just 
another standard medical diagnosis. In that case, 
without making specific reference to it, the plan 
would cover drug treatment to the full extent that 
any other health services delivered by recognized 
therapeutic professionals are covered. On the 
other hand, the plan may overstate coverage 
because the coverage policy does not play out in 
practice, owing to the denial of certification to 
drug treatment seekers by managed care personnel, 
retrospective denial of benefits by utilization 
review personnel, or a refusal to make referrals. 

The second source of data on coverage is claims 
experience, from the point of view of insurers 
paying or of providers receiving these payments. 
Regarding claims payments, there are many 
anecdotes and short-term trend statistics for 
particular companies, but this information is 
virtually always in terms of combined alcohol/drug 
or alcohol/drug/mental health benefit utilization. 
The committee has been unable to access or 
assemble any systematic payer-based data on 
claims payments for drug treatment that are 
reasonably representative of national experience. 



2 74 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



PRIVA TE CO VERA GE 



From the provider end, the various National Drug 
and Alcoholism Treatment Utilization Survey 
(NDATUS) efforts are good indicators of provider 
insurance receipts despite some weaknesses in that 
data base (see Chapter 6). Unfortunately, the 
NDATUS has been too sparse (only two surveys 
since 1980) and too limited in its queries to yield 
a detailed picture of changing private coverage 
experience. 

Explicit coverage certainly expanded in the 1980s, 
and the NDATUS indicates that insurance 
payments expanded as well, but there is no way to 
peer deeply enough into the overall process to be 
completely certain of the relationship. For these 
reasons, this chapter lays out the available 
information but proceeds cautiously to conclusions. 

An important issue in the drug and alcohol 
treatment fields concerns the setting of treatment 
services, especially inpatient versus outpatient and 
hospital versus nonhospital residence. The 
committee could be considered to be basically 
agnostic regarding the specific setting of care, but 
it is far from indifferent to quality and cost 
considerations. The quality of care offered under 
private coverage is not easy to assess because so 
much of it is provided in the outpatient 
nonmethadone and chemical dependency 
modalities, about which the effectiveness data (not 
to be confused with effectiveness as such) are, 
respectively, highly variable and poor. 

Managed care personnel are conversant with and 
justify certification and review decisions based on 
research reports that are virtually all alcohol 
specific. Although it is true that chemical 
dependency treatment for alcohol or drug problems 
is similar and that there is some suggestion that it 
may be less effective for drug than for alcohol 
problems, this information is a weak reed on 
which to rest clinical care decisions. One can 
understand the rationale of payers that, absent 
outcome data, general medical care providers such 
as hospitals at least employ a credentialing and 
quality management system with which payers are 
familiar and in which they have some confidence. 
Moreover, medical necessity exists in some cases 



in the form of serious psychiatric disturbances or 
somatic illnesses, and it is best to err on the side 
of safety—although that margin has become much 
less elastic since the advent of managed care. 
Nevertheless, the committee believes it would be 
far better to insist that drug treatment providers 
begin to provide solid outcome data as a basis for 
recruitment and reimbursement. This policy is not 
only in the treatment buyer's interests but also in 
the interests of the providers— more and more 
sellers will find it worthwhile if not necessary to 
participate in evaluation research to reestablish 
credibility with the private coverage community. 

Cost management is at the core of most health care 
issues today, and drug treatment is no exception. 
It is important to remember that cost-containment 
schemes have proven much more successful at 
curbing utilization rates for expensive services 
such as hospitalization than at reducing unit costs. 
Nevertheless, there is clearly an opportunity if not 
a necessity to curb the unit costs of private care 
for drug treatment. 

The final private coverage question concerns state 
mandates for drug treatment. In 19 states, the law 
requires private insurance to include drug 
treatment as a covered service. These statutes are 
an offshoot of the movement since 1970 to 
mandate private insurance coverage of alcohol 
treatment. Considered in their own right, the 
committee does not find a strong case for the value 
of further such mandates in other states or at a 
national level. In part, the lack of impetus for 
additional required coverage can be ascribed to 
data that show that drug treatment coverage is now 
much more extensive than the mandates would 
suggest; in part, it is because mandates have such 
a narrow application. In the competitive 
environment of private health coverage, in which 
commercial indemnity insurers, third-party 
administrators of self-insured company plans, Blue 
Cross/Blue Shield carriers, and health maintenance 
organizations are fighting for market share, 
mandates that apply only to some of these 
segments hobble their competitive position in ways 
that seem inefficient and inequitable. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



215 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 8 



THE LOGIC OF PRIVATE COVERAGE 

The rationale behind mandating private health 
insurance coverage of drug treatment parallels the 
argument for public coverage: even among the 
privately insured population, there are negative 
external costs to drug abuse and dependence that 
may be reduced by drug treatment, and access to 
treatment is influenced by the price of treatment. 
Coverage of drug treatment by private insurance 
can make the effective price of treatment, at the 
time it is needed, significantly lower (for example, 
80 percent of inpatient or residential costs may be 
covered) than if the full costs of treatment had to 
be paid out of pocket. This lower price means that 
more insured people who need treatment will seek 
it. 

From society's perspective, insurance should 
reduce the effective purchase price of treatment for 
individuals who need it to the point that the 
insured population purchases the socially optimal 
amount of treatment. The socially optimal amount 
of coverage depends on both the effectiveness of 
treatment in reducing external costs, its own costs, 
and the sensitivity of drug abusers to the price of 
effective treatment. The greater the social benefits 
from treatment, the greater should be the coverage 
rate (the share of costs paid by insurance). The 
greater the sensitivity of drug-abusing and 
dependent individuals (who create negative 
external costs) to the price of treatment, the 
greater should be the rate of coverage by 
insurance. 



demand for privately supplied, competitively 
priced treatment or of the responsiveness of private 
demand to the price of treatment. It is known 
that, corresponding to the increase in private 
insurance coverage for drug treatment (effectively 
reducing the cost of treatment to insured drug 
abusers), the private treatment sector appears to 
have grown dramatically. Employer-provided 
private insurance coverage for drug treatment was 
held by 43 percent of employees in medium-sized 
and large companies in 1983 (Morrisey and 
Jensen, 1988) but had increased to 74 percent in 
1988 (Bureau of Labor Statistics, 1989a). During 
this period a number of states enacted mandates 
requiring private health insurance policies to cover 
drug treatment. 

In 1982 the private, for-profit drug treatment 
industry included 159 programs with 9,800 clients 
in treatment; by 1987 it had grown to 735 
programs with 30,000 drug abuse clients in 
treatment. Private insurance reimbursements for 
drug treatment (defined as such by treatment 
providers and thus not contingent on whether 
benefits were explicitly covered under a drug 
treatment clause) increased from $43.5 million in 
1982 to $348 million in 1987. Client out-of- 
pocket reimbursement grew from $35.6 million in 
1982 to $157 million (National Institute on Drug 
Abuse, 1983a; Institute of Medicine analysis of the 
1987 NDATUS). It is not known, however, what 
propoition of the 1982 insurance reimbursements 
and client fee payments went to private-tier 
programs. 



The sensitivity of drug abusers to the price of 
treatment may also depend on their income and 
wealth and on the relative cost of the treatment. 
For a wealthy family, the price of treatment may 
be quite secondary, whereas a lower income 
family may find price to be a major factor. 
Similarly, a cost of $1,500 for a typical treatment 
episode of average effectiveness may have quite 
different implications than a cost of $7,000. 
Access to expensive treatment is more likely than 
access to inexpensive treatment to be sensitive to 
insurance coverage. There has been no 

systematic, empirical economic study of private 



In contrast to residential and outpatient 
nonmethadone treatment, methadone treatment has 
a significant private demand that is not subsidized 
by private insurance reimbursements. Out of $200 
million in total methadone clinic revenues, client 
out-of-pocket payments made up 20 percent. 
Within the $22 million private, for-profit 
methadone treatment system, $17 million, or more 
than 75 percent of revenues, were from client out- 
of-pocket payments. 



276 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



PRIVATE COVERAGE 



The private tier predominantly treats clients who 
are ineligible for public coverage because of their 
level of income. In the absence of insurance 
coverage, these clients would have to pay for 
treatment out of pocket. Because the private 
treatment sector expanded so significantly in 
parallel with the growth of insurance coverage for 
drug treatment, it seems reasonable to suppose that 
whether potential drug treatment clients actually 
enter treatment is in fact quite sensitive to the 
price of treatment. 



THE EXTENT OF PRIVATE INSURANCE 
COVERAGE 

More than 150 million persons are covered by 
private health insurance coverage, the vast 
majority as a benefit of their employment (Chollet, 
1988; Moyer, 1989). The focus of this section is 
the degree to which this coverage extends to drug 
treatment. The details of health insurance 
coverage have been studied periodically by the 
Bureau of Labor Statistics (BLS) during the 1980s, 
primarily through surveys of insurance provided to 
employees of medium-sized and large firms and 
state and local governments. The drug treatment 
coverage afforded to privately insured employees 
of the federal government has also been examined 
recently by the Office of Personnel Management. 
These studies constitute the source material for the 
following discussion. The major limitation on 
these detailed coverage data is that they do not 
include small, nongovernment employers, who 
employ half of the labor force. 

As discussed in Chapter 7, it is possible that in 
some cases drug treatment is reimbursed in the 
absence of explicit coverage. A claim for 
treatment under a drug diagnosis, submitted by an 
appropriately licensed practitioner or accredited 
medical or rehabilitation facility, may simply be 
accepted without question; alternatively, it may be 
submitted under the guise of a different diagnosis 
that is clearly covered (e.g., a psychiatric disorder 
such as severe depression, alcohol dependence, or 
a physical abnormality) . It is difficult to determine 



the extent to which either practice occurs, 
particularly the latter. 

It has been said that alcoholics were treated in the 
past, despite the absence of explicit coverage or 
formal alcohol treatment programs, by simply 
employing different diagnoses within the general 
medical population. This statement cannot be 
disproved, but it is difficult to credit. Certainly, 
many alcohol-dependent individuals received 
medical treatment at times, but most medical 
practitioners had no training in alcohol treatment 
(versus the treatment of, for example, gut ailments 
resulting from excessive alcohol consumption). 
The initial growth spurt of chemical dependency 
providers occurred largely after explicit coverage 
emerged in a number of key states and company 
plans, and its arc of growth has echoed the spread 
of explicit coverage. Nevertheless, the bar to 
treatment was probably much more the lack of 
formal programs, or programs with the medical or 
psychiatric accreditation recognized by insurers, 
than a disincentive to cover the treatment. A Blue 
Cross and Blue Shield Association study (1983) 
concluded that many if not most Blue plans at that 
time covered drug treatment under their mental 
and nervous disorders benefits. 

The most notable evidence for the relevance of 
explicit policy provisions to actual coverage is the 
fact that the growth in private insurance 
reimbursements reported by treatment providers 
has occurred in parallel with the growth of explicit 
coverage. 



Employees of Private Companies 

Medium-sized and large companies (i.e., more 
than 100 employees) have increased their explicit 
coverage for drug treatment significantly since 
1983. In 1988, 74 percent of employees in such 
companies had coverage, an increase from 66 
percent in 1986 and 43 percent in 1983 (Morrisey 
and Jensen, 1988; Bureau of Labor Statistics, 
1989a). The BLS 1988 Employee Benefit Survey 
(EBS) included much more detailed questions than 
any previous survey about the character of such 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



217 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 8 



coverage. Only sketchy statistical summaries of 
the responses to these items are available as yet, 
but these summaries are indicative of the direction 
of this coverage. 

The 1988 EBS survey indicated that 28 million of 
the 3 1 million employees of firms sampled by the 
survey had employer-sponsored health insurance. 
Of the 31 million, 20.6 million were covered by 
plans that had an explicit provision for drug 
treatment or said that as a matter of course they 
would provide reimbursement for detoxification or 
rehabilitation charges. For the other 10 million 
employees of medium-sized and large firms, drug 
treatment episodes were excluded from their health 
insurance coverage. 

Of the 21 million employees with drug treatment 
coverage, nearly all (96 percent) would be 
reimbursed for residential or inpatient drug 
detoxification—which is not drug treatment per se 
(referred to in this connection as "rehabilitation"), 
although it is certainly indicative of a drug-related 
diagnosis. Inpatient or residential treatment was 
covered for 16 million employees, and outpatient 
treatment was covered for 17 million. There were 
limitations on this coverage, however, that differed 
from the standard limitations in the applicable 
health plans.' For the most part, the limitations 
involved a differential cap on dollars or on number 
of days or visits, rather than different copayments, 
deductibles, or maximum out-of-pocket costs 
(Table 8-1). The most frequently imposed 
inpatient limit was 30 days per year; the most 
frequent outpatient limit was 20 or 30 visits per 
year. The typical inpatient limitation was based on 
the average chemical dependency inpatient 
treatment plan. 



Within the public sector, coverage for drug 
treatment is virtually universal for federal 
employees and nearly so for state and local 
employees. But the types of benefits are highly 
variable across the different plans of the thousands 
of state and local government entities. An estimate 
of this coverage is available from a BLS survey 
(Bureau of Labor Statistics, 1988) conducted in 
1987 of benefits provided to employees of state 
and local governments. 

Health insurance coverage for drug treatment in 
1987 was more widespread among publicly 
employed workers than in the private sector. 
Among the 10.3 million full-time employees of 
state and local governments in 1987, the BLS 
study estimated that 94 percent had health care 
coverage, and of these, 94 percent had coverage 
for some type of inpatient hospital treatment for 
drug abuse; it is uncertain how much of this 
coverage applied only to detoxification. Outpatient 
coverage was conservatively estimated at 81 
percent of health plan participants. 

Special limitations were usually imposed on the 
amount of coverage for drug treatment. About 71 
percent of the 94 percent with inpatient coverage 
were subject to special limitations on care that 
were different from those for other health care 
procedures. The most common limitation (38 
percent) was a cap on payment for inpatient days 
of mental health, drug, and alcohol treatment. 
Another 22 percent of covered employees were 
limited in the number of days that would be 
covered just for treatment of drug abuse. The 
most common limitation (15 percent) was a 
maximum of 30 inpatient days; 6 percent had 
higher limits, and 2 percent had lower limits. 



State and Local Government Employees 

Insurance coverage of public employees and their 
dependents is relatively better documented than 
insurance arranged through private employers. 

'The limitations may apply to drug treatment alone, or they 
may apply to drug, psychiatric, and/or alcohol treatment as a 
group. 



Coverage for outpatient services was more 
restrictive. Some form of outpatient coverage was 
available to at least 81 percent of employees 
participating in health insurance plans. Yet for 
only 16 percent of these was the coverage 
equivalent to that for other health problems. 
Charging benefits against mental health limits was 
most common— affecting 35 percent of the 81 
percent with outpatient coverage. Limits on 



218 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



PRIVA TE CO VERA GE 



TABLE 8.1 Details of Drug Dependence/Abuse Benefits (percentage) for the Covered 
Employees of Medium -sized and Large Firms 



Procedure 



Coverage Limitations 





Length of 






Any 


Stay or 


Out-of-Pocket 


Copayment or 


Coverage 


Dollar Cap 


Ceiling 


Deductible 


96 


0.61 


0.05 


0.01 


77 


0.58 


0.05 


0.01 


81 


0.46 


0.10 


0.06 



Detoxification 
Inpatient 

rehabilitation 
Outpatient 

rehabilitation 



Note: Of the 31 million employees of medium-sized and large firms (i.e., 100 or more employees), 90 
percent have some health insurance coverage, and 74 percent of those (i.e., 20.6 million) are covered for 
drug detoxification or rehabilitation procedures. The first column of the table is the percentage of the 20.6 
million with any coverage for a particular procedure; subsequent columns are fractions of the first column 
percentage to which the respective limitations apply. 

Source: Bureau of Labor Statistics (1989a). 



annual visits applied to 13 percent of the covered 
group (9 percent with 30 or fewer visits, 2 percent 
with 50 or more visits). There were coverage 
limitations on maximum dollars, or different 
coinsurance rates or copayments, for 18 percent of 
the provisions. 

Federal Employees 

The federal system had nearly 4 million health 
insurance policies in force in March 1988, 
covering close to 10 million current employees, 
retirees, and dependents. 2 The specifics of federal 
drug treatment benefits were closely examined by 
the Office of Personnel Management (OPM) in a 

2 The federal government employed 3 million persons in 1986, 
of which 2.6 million were full-time employees entitled to 
government-financed health insurance coverage. There were 
also an additional 1.1 million federal retirees. 



document that outlined the pertinent benefits of all 
offerings within the Federal Employee Benefits 
Health Plan (U.S. Office of Personnel 
Management, 1988). Every plan was required to 
offer substance abuse treatment benefits; however, 
there were no specific coverage standards, and the 
nature of coverage varied widely. The common 
characteristic of all plans was to make no 
distinctions between drug and alcohol treatment 
benefits; in addition, their monetary values, as 
calculated by OPM, were all heavily weighted 
toward inpatient treatment. In this sense the 
federal plans seemed more or less to endorse 
chemical dependency treatment concepts, by and 
large tending to focus benefits on hospital-based 
treatment to the exclusion of nonhospital 
residential programs and, more importantly, to 
provide only minimal coverage for outpatient 
services. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



219 



SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 8 



Among the 23 fee-for-service plans available, the 
most common coverage package was judged to 
include $4,000 to $6,000 per year in potential drug 
treatment benefits, with significant special 
deductibles and copayments. There was much 
variation around this average: 8 plans had total 
annual coverage of from $2,800 to $4,000, 10 
were in the $5,000 to $10,000 range, and 5 were 
worth $18,000 or more. In 15 policies, more than 
90 percent of the value of these benefits was 
specifically designated for inpatient treatment in 
hospital-based facilities. Five fee-for-service plans 
offered no coverage for outpatient services, and 7 
others limited such services to $250 to $400 per 
year. Benefits of $750 to $1,000 per year were 
provided by 6 plans, whereas 3 offered benefits 
worth $1,500 to $2,500. 3 

Health maintenance organizations (HMOs) had 
benefits similar in many ways to fee-for-service 
plans, although the major HMOs seemed to impose 
fewer constraints and limitations with regard to 
inpatient care and the same or fewer limitations 
with respect to covering outpatient care. Nearly 
all of the largest HMOs covered inpatient 
treatment for up to 30 days with negligible or 
modest copayments. Outpatient treatment was 
covered by all HMOs, generally to a maximum of 
20 annual reimbursed visits, which is close to, 
although somewhat short of, the average outpatient 
nonmethadone treatment plan. A significant 
number of plans stipulated copayments of $20 (or 
more) per outpatient visit, whereas about half the 
regional plans under one large HMO covered "all 
necessary outpatient counseling" at minimal 
copayment rates. 



Employers and Coverage Decisions 

Although the public sector has made a limited 
amount of treatment available for the past 20 years 

3 Nine policies included stop-loss limits (payment for any annual 
out-of-pocket expenditures for alcohol/drug treatment that 
exceeded a specific amount) ranging from $4,000 to $8,000, 
which were further subject to lifetime maxima. Another 9 
policies specified out-of-pocket maxima of $25,000 to 
$50,000; 4 had no explicit lifetime maximum. 



(primarily directed toward criminally active drug 
abusers), until recently there has been little 
recognition of the drug problem in the work force. 
Private insurance policies gave little explicit 
recognition to the need for this type of treatment. 
Drug treatment, if delivered, was reported under 
medical diagnoses. As recently as 1983, only 43 
percent of workers in medium-sized and large 
private companies had explicit coverage for any 
kind of drug treatment (Morrisey and Jensen, 
1988). 

The reasons for the lack of coverage are many and 
varied, as are the reasons coverage has 
dramatically increased over the past 15 years. Not 
the least of the problem has been the lack of 
recognition or actual denial among employers that 
there were many or any drug-abusing and 
dependent individuals in their work force. 
Furthermore, like alcohol problems, drug 
problems have at best been viewed as a character 
flaw or personal weakness and at worst as "willful 
misconduct. " 

Another problem has been uncertainty on the part 
of insurers. There is uncertainty about the extent 
to which the benefit will be used and how much to 
pay for these services. It is unclear what kind or 
kinds of treatment should be covered—what works 
and what the outcomes are. This uncertainty 
makes it difficult for insurers to price the benefit 
reasonably without leaving themselves (or the self- 
insured entity) exposed to large potential losses if 
usage or cost per treatment is greater than 
expected. This uncertainty can motivate 

overpricing of the benefit until sufficient time as 
the benefit may be rated based on experience. 
Inflated pricing for a benefit may discourage 
employers (or individuals) from purchasing the 
benefit. 

Implicit in the rationale for the addition of 
coverage for drug treatment is that drug treatment 
may pay for itself, either through improved worker 
productivity or through a "health cost offset" 
effect. There has been no rigorous analysis of the 
productivity-improving effects of chemical 



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dependency drug treatment. However, a large and 
growing literature (Holder and Blose, 1986; 
Holder and Hallan, 1986) suggests that the cost of 
treating alcoholics is recovered subsequent to 
treatment by reducing their insurance claims for 
health services. The conclusions of this literature, 
although subject to methodological weaknesses, 
have by inference been applied to justify drug 
treatment, even though there are no studies of cost 
offsets with clients with primary drug abuse 
problems. 

In the committee's view, the justification for 
insurance coverage for drug treatment does not and 
should not rest on insurance cost offsets. Most 
health care services are covered whether or not the 
treatment renders cost offsets. Many terminal or 
chronic illnesses might not be treated if the criteria 
of cost-effectiveness were applied. Advanced- 
stage cancer, stroke, and heart disease are 
primarily incident in older persons who have 
relatively short life expectancies even without the 
specific disease; they often have poor prognoses, 
and aggressive treatment tends to be very 
expensive (Hartunian et al., 1980). Similarly, 
organ transplants involve high costs and are 
undertaken with the expectation of modestly 
increasing life expectancy or quality of life but not 
necessarily of saving costs for the insurance plan. 
In the sense that drug treatment has no proven 
expectation for immediate reduction of health care 
expenditures and can be expensive, it is analogous 
to coverage of treatment for many terminal or 
life-threatening illnesses. There are, however, 
valid concerns about directing patients to the least 
expensive of equally effective treatments or 
providers. These concerns have been the most 
important recent trend influencing the extent of 
private coverage and are discussed in the next 
section. 



TRENDS AFFECTING PRIVATE 

COVERAGE: COST CONTAINMENT OF 

HEALTH BENEFITS 

The major trend that is now affecting private 
coverage for drug treatment is unquestionably the 



increasing emphasis on cost containment. There 
are both general and specific reasons that have led 
purchasers and underwriters of group policies to 
take long, hard looks at drug treatment benefits. 
Generally, the cost of health services and 
particularly of health insurance has grown at an 
uncomfortably high rate during the past two 
decades. Health care expenditures now make up 
about 11.5 percent of the U.S. gross national 
product, up from 7.5 percent 20 years ago. 
Private health insurance expenditures were $71 per 
capita in 1970 and $552 per capita in 1987 (Health 
Insurance Association of America, 1989). In the 
wake of these increases has come an ever- 
intensifying search for ways to reduce the cost of 
health insurance benefits by private as well as 
public insurance plans. 

The percentage of total health insurance outlays 
spent on drug treatment is small. Total health care 
outlays by commercial insurers, Blue Cross/Blue 
Shield carriers, and HMOs were $140 billion in 
1987. The 1987 NDATUS figure of just under 
$350 million for health insurance payments to all 
surveyed drug treatment programs amounts to just 
0.25 percent of total private insurance outlays. 
Even if the NDATUS undercounted by as much as 
half, which would inflate the committee's estimate 
to $700 million, this figure is still only 0.5 percent 
of total health insurance outlays. One might 
further estimate, guided by reports from the public 
sector (see the section on detoxification in Chapter 
7), that as few as one-seventh of all private 
detoxification episodes led to the initiation of 
rehabilitation treatment. Using the ICF 

Incorporated (1987) report on the costs of private- 
tier inpatient detoxification and rehabilitation 
episodes as a guide, one would be led to estimate 
that about $700 million dollars more in health 
insurance dollars might be spent on drug 
detoxification outside of the identified treatment 
system. This outside figure of $1.4 billion for 
drug detoxification and rehabilitation is about 1 
percent of total private health insurance outlays. 

Of course, given the incomplete coverage of 
treatment, individual plans that do have adequate 



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coverage may be expected to spend a proportion 
higher than this amount. 4 The committee reviewed 
a small number of unpublished actuarial ratings of 
drug treatment benefits that are typical of the 30- 
day/30- visit coverage seen around the country. 
The most careful and complete of these ratings 
indicated that the total costs of drug detoxification 
and treatment in a Blue Cross plan in one of the 
largest urban areas in the country were on the 
order of 0.7 percent of total private insurance 
outlays. 

Nevertheless, in today's environment of general 
concern about health costs, insurers and funders of 
group plans have begun to single out for special 
attention the components of their insurance 
packages that are causing the greatest part of their 
payment increases. Insurance benefits for drug 
abuse, alcoholism, and mental health have had 
dramatic increases in utilization in the past five 
years. Although this rise in utilization would 
generate interest in this expenditure area under any 
circumstances, there have been additional concerns 
raised recently owing to skepticism about the cost- 
effectiveness— and, in some quarters, the 
effectiveness as such—of alcohol treatment. Close 
scrutiny of the evidence has led some researchers 
to conclude that more expensive hospital-based 
inpatient alcohol treatments appear to be no more 
effective than less expensive treatments (Saxe et 
al., 1983; Miller and Hester, 1986). The 
committee's companion Institute of Medicine 
(1990) panel has recently concluded that, in 
general, a significant number (about one- third) of 
the persons now cared for in inpatient facilities 

4 The relationship between the degree of coverage and the 
claims experienced is subject to several sources of error. For 
example, when employee health benefit claims are processed 
by or available to a firm's personnel department, some 
individuals who would be covered for drug treatment services 
may be reluctant to claim the benefit for fear of jeopardizing 
their job standing. There is also a widespread belief among 
payers and providers—although no studies have been conducted 
or made available to support this belief— that some clinicians 
routinely or occasionally obfuscate the diagnosis of drug abuse 
or dependence (perhaps by masking it with a different 
diagnosis, such as depression) to increase the likelihood of 
reimbursement in those instances in which psychiatric 
diagnoses are covered but drug or alcohol diagnoses may not 
be. 



could receive appropriate care in less restrictive 
and less costly settings. 

This finding is a problem for drug treatment 
because this coverage is in some sense an 
outgrowth of alcohol treatment coverage, and most 
of the private tier evolved into chemical 
dependency programs from an alcohol treatment 
focus. As the value of more expensive alcohol 
treatment programs has come into question, 
insurers have been quick to apply new limitations 
on coverage for alcohol treatment, largely in the 
form of aggressive managed care (Health Care 
Advisory Board, 1988; Korcok, 1988a,b; 
Malcolm, 1990). 

Insurers, managed care companies, and employers 
are also increasingly critical of the lack of data on 
outcomes of chemical dependency treatment (cf. 
Chapter 5). Although increasing numbers of 
chemical dependency providers are compiling basic 
follow-up data on their clients, they do not yet 
have the necessary foundation in rigorously 
conducted outcome studies. Moreover, the 
outcome data compiled by and for private-tier 
providers (e.g., Comprehensive Care Corporation, 
1988; Hoffmann and Harrison, 1988) are 
indicating that clients with drug problems have 
poorer outcomes than clients with primary alcohol 
problems. 

In the face of increasing overall health insurance 
costs and doubts about the efficacy of more costly 
forms of alcohol treatment, the buyers of 
insurance, bearers of insurance risk (particularly 
employers), and third-party administrators have 
taken steps to attempt to reduce the increase in 
health costs. These steps have assumed the form 
of general policies for the entire fabric of health 
insurance and policies targeted specifically at drug 
and alcohol treatment. A prevailing hypothesis 
about health care costs holds that lack of 
competition has been responsible for a significant 
part of the increased costs (Fuchs, 1988; see also 
other articles in the same issue). It is argued that, 
under the old insurance plans, health services 
suppliers had inadequate incentives to keep the 



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costs of services low. In fact, it has been 
suggested that the incentives were all in the 
direction of inflating health expenditures and prices 
(supplier-induced demand for health services). 
The health financing system consequently has been 
changing dramatically in the past decade, 
developing new incentives for providers and 
consumers as well as creating new public and 
private regulatory instruments. 

Drug treatment has been caught up in this 
revolution. Supplier incentives to cut costs have 
been increased by encouraging capitated or prepaid 
health plans to develop. Health provision plans 
like HMOs and individual practitioner associations 
(IPAs) have pioneered in incorporating incentives 
to contain costs. Although rare at this stage, 
provider incentives for efficiency have been 
increased by the use of prospective reimbursement 
rates for services, like the diagnosis-related group 
rates established under Medicare for reimbursing 
hospital stays. Capitated and fee-for-service plans 
have been negotiating reduced-fee arrangements 
with preferred provider organizations (PPOs) in 
return for directing plan participants to these 
providers. 

Consumer incentives to reduce costs have also 
been changed by modifying benefit 
schedules— increasing deductibles and co-payment 
rates (Bureau of Labor Statistics, 1987). 
Consumers have also borne more of the visible 
cost of insurance through increasing employee 
contributions to cover the premium— in other 
words, by reducing salaries and wages rather than 
increasing fringe benefits. Changes in deductibles 
and copayment rates are designed not only to shift 
aggregate costs from the risk pool to the individual 
beneficiary but also to cause consumers to pay 
more attention to the prices of particular benefits 
and services. 

Self-insurance administered by a third-party claims 
processor is an approach taken by an increasing 
number of private firms to reduce their health 
insurance bills. This strategy is designed to yield 
savings to the company through several avenues: 



avoiding state taxes on the premiums paid to 
commercial and Blue Cross/Blue Shield plans, 
giving the company control over the interest 
(liquidity) earned on annual premiums, avoiding 
payments to a financial intermediary to bear the 
risk associated with any kind of insurance, and 
avoiding expensive state mandates for insurance 
coverage. Self-insured companies assume the 
financial risk formerly born by insurers, retaining 
a third-party administrator to process claims. 

A variety of strategies generically known as 
managed care have been introduced to regulate 
more closely the use of health services by 
beneficiaries or, alternatively, the supply of health 
services to beneficiaries by providers. These 
strategies include prospective certification or 
preadmission review (PAR) of hospital stays, 
utilization review during or after discharge, the use 
of preferred providers, and specialized high-cost 
case management. PAR requires that patients 
receive prior approval of admission to a hospital 
from the insurer to be entitled to full 
reimbursement for costs. Utilization review 
involves midtreatment or even retrospective review 
by insurers (or their managed care agents) of the 
"appropriateness" of services delivered, with 
denial of insurance reimbursement for unapproved 
services. Preferred providers often have contracts 
with the insurers about the level and nature of care 
to be delivered for a particular type of case. 
Under some contractual arrangements, managed 
care providers have explicit short-run financial 
(profit) incentives to reduce the utilization of 
health care services of beneficiaries under their 
supervision, although this arrangement is not true 
under fee-for-service contracts. Yet under fee-for- 
service contracts, a managed care contractor must 
eventually demonstrate success at controlling costs 
or risk losing the contract. 

The objective of managed care strategies is to 
accumulate information about accepted clinical 
practices and the cost of these practices and to 
codify appropriate treatment strategies as protocols 
for permitting or disallowing reimbursement for 
particular services in particular instances. With 



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attempting to address the problems of limited 
patient knowledge about health services and the 
potential for supplier-induced demand (Fuchs, 
1988). 

If managed care strategies for drug treatment are 
backed by research findings on treatment 
effectiveness, they can help guarantee needed 
access to quality treatment while containing the 
costs of insuring it. Under the powerful prod of 
negotiated services and managed care, private 
coverage has been moving away from its 
orientation toward acute inpatient care models. In 
this respect the private drug treatment system is 
repeating the earlier cycle of the public tier. 
Hospital-based treatment was virtually eliminated 
from the public drug treatment strategy in the mid- 
1970s when it was concluded to be no more 
effective than other treatment approaches but 
substantially more expensive (Strategy Council on 
Drug Abuse, 1975; Besteman, 1992). Public 
resources were redirected toward outpatient and 
nonhospital residential treatment, with the 
consequent ability to treat many more people for 
the same dollars. Managed care has the objective 
of identifying just such efficiencies. 

On the other hand, coverage for services received 
from residential providers must be carefully 
framed. Some clients undoubtedly require 
residential treatment, and insurers need to 
recognize the distinctive value of residential 
providers, who may be affiliated with hospitals and 
even located in such settings but are disjoined from 
the requirements—including the financial burdens— 
of acute hospital care. Many insurers have in the 
past failed to recognize such providers as eligible 
for reimbursement, which may have contributed to 
excessive utilization of hospital inpatient treatment 
in the past. 

As managed care strategies have matured, they 
have come under increasing scrutiny and criticism 
from alcohol and drug treatment providers 
following aggressive moves by managed care 
companies to cut the costs of treating drug and 
alcohol abuse. Taking cues (that is, preadmission 
and utilization review protocols) from the reviews 



by Saxe and colleagues (1983) and Miller and 
Hester (1986), which were entirely focused on 
alcohol and not drug treatment, managed care 
reviewers have attempted to direct all drug clients 
away from inpatient programs and toward 
outpatient services; as a result, they are certifying 
shorter and shorter inpatient stays. This trend is 
viewed with particular alarm by employee 
assistance program (EAP) staff, chemical 
dependency treatment programs, and therapeutic 
communities that have received accreditation and 
recognition but are increasingly being asked to 
shorten treatment plans in ways that defy all of 
their therapeutic experience. 

Employee assistance program professionals are 
potentially important actors in the managed care 
system. There appears to be an uneasy 
relationship between EAP professionals and 
managed care providers because of the overlap of 
some of their respective roles. In many companies 
that use EAPs, the staff of the program have 
traditionally owned the role of "gatekeeper" to 
treatment, with the responsibility for assessing 
troubled employees, diagnosing their problems, 
and referring them to appropriate treatment. 
Because many EAP staff come from the alcoholism 
field and have had little professional contact with 
any other treatment modalities, as EAPs broadened 
their focus to deal with drug problems, the drug 
treatment of choice was by default the chemical 
dependency model. With the recent pressure on 
this model from cost-containment forces, the EAP 
professionals who were committed to it have, by 
and large, felt as though they were in a virtual 
state of war with managed care contractors: their 
referrals to treatment subject to review by external 
practitioners selected by the managed care firm, 
with fully reimbursed care available only through 
providers selected by that firm, with whom the 
EAP has had no previous relationship or 
knowledge of their practices. 

There is clearly a significant overlap in the roles 
of EAPs and managed care providers, and this 
overlap may become a bureaucratic barrier that 
complicates access to needed treatment. However, 
EAPs are primarily charged with returning 



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overlap may become a bureaucratic barrier that 
complicates access to needed treatment. However, 
EAPs are primarily charged with returning 
problem employees to satisfactory performance and 
promoting employee health over the long term. 
EAP personnel often establish relationships with 
treatment agencies to achieve these goals, 
sometimes with the consideration in mind of using 
treatment resources efficiently. Managed care 
personnel are primarily responsible for reducing 
the costs of health care episodes while ensuring 
that beneficiaries receive good-quality care. There 
are tensions between EAP responsibility for 
employee health and managed care accountability 
for cost control— often backed by contractual 
promises or inducements to reduce stipulated 
benefit payouts by specific percentage targets. Yet 
the tension may be a creative one if EAP and 
managed care personnel work together. The best 
relationships between EAP and managed care 
personnel occur when EAP staff are fundamentally 
involved in the adoption of managed care strategies 
and have a clearly delineated role in making 
assessments and referrals and in choosing 
providers. These relationships can be further 
improved by commitments to collecting better data 
on treatment processes and outcomes. The worst 
case seems to be when corporate benefits managers 
adopt managed care plans with minimal 
consultation of the EAP staff and no forethought 
about how the EAP will interface with managed 
care. 



PRIVATE INSURANCE AND STATE 
MANDATES 

The private tier of providers, which is linked to 
the corporate world of employee assistance 
programs, originated as and still is primarily an 
alcohol treatment system. Private providers have 
joined with the labor movement and a few 
underwriters and corporations in major educational 
efforts since about 1970 that have steadily 
increased the number of health plans that 
specifically cover alcohol and drug treatment. 
Also as a result of these efforts, state insurance 



mandates represent an important initiative relative 
to private coverage for drug treatment. A total of 
18 states plus the District of Columbia have passed 
laws mandating some coverage for drug treatment. 
The objective has been either to require insurance 
plans to include coverage for this problem in their 
basic package of benefits or at least to require 
them to offer to sell such a benefit. States clearly 
view health insurance as a mechanism through 
which an increasingly costly public problem can be 
privatized. The mandating of drug treatment 
benefits began and is best seen as an offshoot of 
the mandation of alcohol treatment. 

Access to Coverage 

The first issue about the relevance of state 
mandates for coverage of drug treatment is 
whether they in fact make coverage more available 
to beneficiaries. As of this writing, 10 states plus 
the District of Columbia mandate the inclusion of 
drug treatment benefits in group policies . Another 
8 states mandate that insurers at least offer this 
benefit as an optional addition to basic coverage. 
Each state has a similar or identical mandate for 
coverage of alcohol treatment. 5 

The extent of coverage (discussed earlier) for the 
31 million employees (plus dependents) of 
medium-sized and large corporations and for 13 
million public employees is much greater than 
would be indicated by the mandates enacted by 
state legislatures. States with mandates to cover or 
offer to cover drug treatment were home to 11.9 
and 16.6 percent of the U.S. population, 
respectively. But in 1988, 74 percent of private 
employees in medium-sized and large firms that 
had company-sponsored health insurance had some 
kind of coverage for drug treatment. Among 
public employees the coverage rate in 1987 was 94 
percent. Thus, the extent of insurance coverage 
for drug treatment is greater than would be 
indicated simply by state mandates. 

B Another 1 states mandated provision of alcoholism coverage, 
and 9 more states mandated the offer of optional coverage for 
alcohol treatment. Altogether, 37 states plus the District of 
Columbia, comprising 85 percent of the U.S. population, have 
mandates regarding alcohol treatment coverage. 



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A crucial issue with state insurance mandates is 
that private corporations that self-insure under 
federal ERISA (Employee Retirement Income 
Security Act) statutes effectively evade any 
insurance coverage mandates that are legislated by 
states. State coverage mandates are not likely to 
be a necessary or sufficient cause for any company 
to self-insure, but there is a clear tendency for 
self-insured companies to be less likely to cover 
drug treatment than companies with Blue 
Cross/Blue Shield coverage or employees covered 
under HMOs. Morrisey and Jensen (1988) found 
that employees of self-insured companies were 
much less likely to be explicitly covered for drug 
treatment (56 percent of employees were covered) 
than employees insured by a Blue Cross/Blue 
Shield carrier (76 percent) or an HMO 6 (88 
percent). Policies with commercial insurers, 
however, were the least likely to offer drug 
treatment coverage (50 percent). A further analysis 
by Jensen (1988) indicates that state mandates are 
not significant predictors of whether a company 
self-insures when other characteristics of the 
company are examined. The important predictors 
of self-insurance were the size of the state tax on 
health insurance premiums, the nature of the 
industry, and the characteristics of workers of the 
company. Self- insured companies do so for more 
economically compelling reasons than to avoid 
coverage mandates for drug or alcohol treatment. 
On the other hand, an accumulation of several 
relatively inexpensive mandates may be expensive 
enough for a company to opt for self-insurance. 

Adequacy of Coverage 

The adequacy of mandated coverage for drug 
treatment is highly problematical because coverage 
for drug abuse is for all practical purposes an 

"There is a widespread belief among chemical dependency 
providers that HMO coverage of drug treatment is less 
extensive in practice than on paper. For example, providers 
assert that HMOs vigorously resist authorizing hospital stays, 
insist on group rather than individual counseling, and avoid 
treatment by high-cost care givers such as psychiatrists in 
favor of lower cost counseling professions. There is little 
documentary evidence on the extent of these practices or their 
effects on the outcomes of drug treatment of HMO clients. 



afterthought to coverage for alcohol treatment; 
where coverage for drug treatment is mandated, it 
is virtually identical to that for alcohol treatment. 
Only in Maryland are there different limits on 
coverage for drug and alcohol abuse, and in that 
case drug treatment has a lower minimum 
coverage than alcohol treatment. 

Most of the state legislatures have virtually 
mandated only one modality, chemical dependency 
treatment, and made barely enough provision for 
a typical course of outpatient nonmethadone 
treatment. Of nine state drug abuse mandates that 
specify minimum days of inpatient coverage, six 
call for minimum annual coverage of 28 or 30 
days; the other three call for minima of 21, 45, 
and 60 days. 7 

Three other state mandates cover minimum annual 
dollar limits for inpatient reimbursement, with 
values of $3,000 (per 30-day period), $4,500, and 
$9,000, respectively. The $9,000 coverage is for 
hospital-based inpatient rehabilitation treatment and 
is marginally or less than adequate for a 28- to 30- 
day stay. The lower dollar limits clearly preclude 
the use of most chemical dependency treatment 
programs at the rates typically charged. There is 
a great deal of evidence, however, that these rates 
can be drastically reduced without cutting into 
patient care costs by simply reducing the 
extraordinary rates of return that characterized 
these programs during the 1980s (Health Care 
Advisory Board, 1988). Another state mandates 
coverage for residential treatment "pursuant to a 
treatment plan" with no minimum specified for 
days of care or dollars. Three states mandate 
$1,500 to $2,000 annual coverage for outpatient 

7 In a survey conducted in 1986 (ICF Incorporated, 1987), 230 
chemical dependency programs charged an average of about 
$265 per day-about 10 percent above the average national 
daily charge for a semiprivate hospital room in 1986 /Health 
Insurance Association of America, 1989)— for an average of 28 
days in treatment, making a typical episode of treatment (if it 
included initial detoxification) cost approximately $7,800; with 
intervening health care cost inflation, that charge would now 
be $1 1,000 if no other factors intervened. Charges differed 
little for privately supported inpatients treated in programs 
located in general acute care hospitals or in freestanding 
(although often hospital-affiliated) settings. 



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treatment of drug abuse but specify no minimum 
coverage for inpatient services. Another three 
states simply require policies to offer optional 
coverage of an unspecified nature. 

Cost Containment 

State mandates recognize several mechanisms for 
containing the costs of drug treatment. The 
primary method allowed for this purpose is the use 
of less expensive competitive facilities for delivery 
of residential treatment. Alternative treatment 
facilities are recognized by 34 of the 35 states that 
have drug or alcohol abuse mandates, usually 
under the proviso that the facility be licensed by 
the state substance abuse authority or accredited by 
the voluntary Joint Commission on Accreditation 
of Healthcare Organizations (JCAHO) or the 
Commission on Accreditation of Rehabilitation 
Facilities (CARF). 

Many nonhospital residential facilities have lower 
cost structures than hospital-based programs and 
charge appreciably less per day of treatment. 
They do not have the continuing onsite medical 
facilities, equipment, and personnel required for 
hospital licensure, but then again, these capacities 
are not needed for most drug treatment clients. 
Insurance plans thus are often given the option of 
covering drug treatment in lower cost facilities. A 
frequent criticism of health insurance plans by 
nonhospital treatment providers, however, is that 
many insurers and third-party administrators do 
not in fact cover treatment in nonhospital facilities, 
even though these facilities are licensed by the 
state and accredited by JCAHCO or CARF for 
drug and/or alcohol treatment. Although it may be 
in the financial interest of insurers to cover 
treatment in these facilities, insurance plans 
reportedly have been reticent to do so because of 
uncertainty about the quality of care delivered in 
nonhospital-based programs. 

Two state drug coverage mandates, those of North 
Dakota and Arkansas, specify flexibility for the 
policy beneficiary. In North Dakota the basic 
mandate is for a minimum of 60 days in a hospital 



plus 120 days of partial hospitalization and 20 
outpatient visits. Part of the inpatient care may be 
exchanged for partial hospitalization care on a two- 
for-one basis. Arkansas mandates a minimum total 
value of services of $6,000 per year, delivered in 
hospital or nonhospital freestanding facilities or by 
outpatient providers. Alabama in its alcohol 
treatment mandate allows a trade-off of inpatient 
(hospital) care for treatment in a state-licensed, 
short-term residential alcohol treatment facility or 
a three-for-one exchange for outpatient treatment. 

The 15 jurisdictions that mandate minimum levels 
of outpatient benefits range in value from $900 to 
$2,500 per year, or 20 to 45 visits (hours) per 
year. These benefits tend to have maximum 
copayment rates of about 20 percent. 

The Value of Additional Mandates 

The committee has reservations about the value of 
additional state mandates for drug treatment 
coverage. First, coverage for drug treatment is 
more widespread than the extensiveness of state 
mandates would indicate. There are clearly 
reasons other than mandate enactment for the 
spread of coverage— perhaps the increasing 
realization by employers that drug treatment is a 
valuable benefit for their employees and for the 
company. Second, state mandates do not apply to 
the growing number of companies that self-insure 
under the federal ERISA statutes, especially 
companies with more than 500 employees, of 
which the percentage self-insuring is now at least 
60 percent. ERISA does not deal with the 
coverage of drug treatment services or other 
matters that states have attempted to address with 
mandates. Third, the nature of coverage mandated 
by many states is too much captive to the chemical 
dependency model, which is not the only available 
modality of drug treatment. 

Finally, state benefit mandates are quite rigid in 
their structure. Only a few states permit flexibility 
or the trading-off of benefits of different kinds to 
encourage treatment purchasers and providers to 
seek the most cost-effective treatment choices. 



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Typically, states mandate a minimum benefit for 
inpatient treatment and a minimum benefit for 
outpatient treatment, with no opportunities to 
substitute less inpatient for more outpatient or 
greater amounts of less expensive treatments for 
smaller amounts of more expensive ones. Only 
one state, Oregon, mandates what seems, in the 
committee's view, to be the most sensible option: 
a simple minimum dollar value of insured drug 
treatment coverage. If that dollar value is realistic 
in terms of competitive prices, it enables 
companies and individual beneficiaries to seek the 
best treatment values while using managed care 
strategies to guard against inappropriate use and to 
collect useful information about provider 
characteristics and performances. 



CONCLUSIONS 

Extent, Costs, and Trends of Coverage 

The private tier of drug treatment providers is 
largely oriented toward treating the employed 
population and their family members. The 
majority of this population, about 140 million 
individuals, have specifically defined coverage for 
drug treatment in their health insurance plans. 
About 48 million others who are privately insured 
do not have specifically defined coverage for drug 
treatment, although coverage may occur de facto 
under general medical or psychiatric provisions. 
As of 1988, the health plans of about 67 percent of 
full-time employees of firms with 100 or more 
employees offered specifically defined coverage 
for some types of drug treatment, although the 
actual extent of benefits under these defined 
coverage provisions is uncertain. 

Actuarial studies of claims experience yield rather 
modest estimates for the overall cost of covering 
drug treatment. Data about drug treatment 
expenditures tend to be buried under more 
inclusive headings and behind "horror stories" 
involving troubled adolescents with multiple 
diagnoses spending months in psychiatric facilities. 
Nevertheless, the committee estimates that a health 



plan with typical coverage now spends 1 percent 
or less of its total outlays for explicit drug 
treatment, most of it for hospital inpatient charges- 
-with a large fraction of that cost devoted to 
detoxification. However, there has been a 
substantial apparent growth in the rate of drug 
treatment claims in recent years, particularly for 
insured adolescents. It is difficult to know how 
much of this increase is actually due to the 
replacement of psychiatric or medical diagnoses 
with more revealing or accurate drug problem 
diagnoses versus an increased demand for drug 
treatment in the insured population. Possibly, both 
processes are occurring. 

Although this growth is disturbing to the degree it 
increases the aggregate cost of health insurance 
premiums, it is desirable if it means that an 
increased number of those who need treatment are 
seeking and receiving it, particularly if the 
treatment delivered is appropriate, effective, and 
reasonable in cost. Some payers, however, 
reacting in part to the high costs in a small number 
of cases and the high incidence of recidivism, have 
strongly questioned the value of drug treatment 
episodes. There is a movement at least 
rhetorically to view drug treatment as part of the 
non-medical/surgical fringe of health coverage that 
may be differentially limited (rather than cut back 
evenly with other benefits across the board) to trim 
increasing overall costs. 



Mandating Drug Treatment Coverage 

There are legislative mandates in 1 8 states plus the 
District of Columbia that require certain categories 
of employer-supplied group health plans to 
specifically cover— or offer optional coverage for— 
drug and alcohol treatment. (Another 19 states 
require some degree of coverage for alcohol 
treatment only.) In the committee's judgment, 
private coverage of drug treatment is beneficial to 
individuals and employers and should be included 
in every health package; however, legislative 
mandates at the state level have not necessarily 
proved to be an effective way, and are clearly not 



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PR! V ATE CO VERA GE 



the only way, to induce adequate coverage. Most 
of those in the insured population whose plans 
include explicitly defined coverage for drug 
treatment reside in states that do not have 
legislative mandates for such coverage. Moreover, 
the political process has often produced less-than- 
optimal mandatory provisions that are difficult to 
adjust and overly rigid and that pay too much 
attention to limits on the length of stay and the 
number of visits rather than to the cost and 
effectiveness of treatment. Most mandatory 
provisions have the constraining effect of funneling 
people toward one particular modality of treatment 
by favoring inpatient stays of prespecified lengths. 

The committee believes that the development of 
soundly derived standards for admission, care, 
and program performance will do more at this 
time to generate appropriate coverage than a 
further set of mandates. If mandates are to be 
used, efficiency and fairness dictate that they be 
applied to all competing insurers. Yet if the 
private market leaves large numbers of the insured 
population without coverage for drug treatment, it 
may be necessary for government to intervene. 
Such action could involve subsidies for drug 
treatment coverage, tax preferences for certain 
kinds of coverage, or mandates, with the choice 
dependent on judgments about the incidence, 
efficiency, and equity of alternative ways of 
financing coverage. 



Optimal Coverage Provisions 

Private insurance provisions (including most 
legislatively mandated benefits) often include 
financial incentives for beneficiaries to seek more 
expensive hospital or residential treatment. 
Insurance coverage until very recently has heavily 
favored hospital-based inpatient stays over 
outpatient visits and continues to encourage the 
"gold standard" medical model rather than more 
explicitly psychological or socially oriented 
treatment. Although residential drug treatment, 
including hospital treatment, often serves clinically 
important functions such as permitting intensive 



therapy, isolating the patient from an adverse 
environment, or treating concurrent psychiatric or 
medical complications, the hospital-specific 
components of such programs (e.g., 24-hour onsite 
medical coverage) do not seem to be the 
therapeutically important elements in the drug 
treatment programs that are sited there, even 
though the availability of these components is used 
to justify charging acute care hospital rates for all 
clients. 

There is currently a movement afoot to reduce 
hospitalizations, mainly as a result of cost- 
containment measures, especially precertification, 
utilization review, and negotiation of preferred 
provider arrangements. The committee's principal 
response to these developments is to favor them in 
general, but it specifically recommends that 
curbs on unit-of-service costs for inpatient care 
be strengthened and that payers insist on the 
generation of reliable performance/outcome 
data. There are two reasons why it would be 
unwise to institute blanket denials of coverage for 
hospital-based drug treatment. First, in some 
states and localities, hospital-based programs are 
the only sites providing residential treatment. 
Second, a certain proportion of the individuals 
who seek drug treatment also have problems for 
which a course of acute hospital care is 
appropriate, namely, complications or co-occurring 
medical or psychiatric disorders. 

Altogether, such cases in which it may be 
justifiable and necessary to initiate drug treatment 
services in a hospital setting may total one-fourth 
of privately covered clients who seek drug 
treatment. This figure is only guesswork, 
however, pending the advent of objective 
diagnostic assessment, systematic follow-up data 
collection, and systematic services research and 
evaluation of private treatment programs. 
Whatever the numbers involved, the committee 
recommends that drug treatment services at 
hospital sites be reimbursed separately from 
other diagnoses or hospital services, as there 
appears to be no compelling reason why these 
services for most drug treatment patients should 



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SUBSTANCE ABUSE COVERAGE STUDY, VOLUME 1, CHAPTER 8 



routinely command fees comparable to acute 
care rates rather than to reasonably competitive 
residential treatment rates. 

Insurers and employers need to become better 
informed about drug treatment and to structure 
their benefits to support controlled access to a 
broad range of the most appropriate, effective, and 
efficiently priced treatments rather than to a 
narrow (and expensive) band of options that are 
similar in form to the treatment of acute medical 
conditions. Private insurance, health maintenance 
organizations, and other health financing plans 
should cover appropriate, adequate, cost-effective 
drug treatment and not reimburse the cost of 
excessive, inappropriate treatments or charges 
(Table 8-2). 

The committee recommends that private risk 
bearers, in lieu of arbitrary payment caps or 
exclusions, institute rigorous, independent 
preadmission review (where possible) and 
concurrent review of all hospital and residential 
admissions as a way to control access and 
utilization, ensure appropriate placement, and 
manage costs. Preadmission review may not be 
necessary for outpatient admissions, but early 
concurrent utilization review is important for 
outpatient treatment to ensure that diagnostic 
criteria are observed and charges are reasonable. 
Employee assistance programs can serve as 
utilization managers in cases in which their 
personnel have appropriate training for matching 
patients to treatment. Hospital utilization should 
be managed under the same terms as recommended 
for public coverage (see the section on utilization 
management in Chapter 7). In general, utilization 
management and indicators of performance are 
needed to meet concerns about costs and 
inappropriate treatment. In this area, as in other 
dimensions of health care, the stress should be on 
efficient delivery of effective care, in which 
responsible clinical innovation is encouraged, 
tested, and used when its worth is demonstrated. 



the publication of regular, independent follow- 
up surveys to determine client outcomes, taking 
into account data on admission characteristics 
such as problem severity. Providers and payers 
should be able to compare treatment results with 
overall program norms to ensure that good 
performance is maintained and poor performance 
recognized when it occurs. 

The committee recommends that the provisions 
of drug treatment benefits, including 
deductibles, copayments, stop-loss measures, 
and scheduled caps, be similar to provisions for 
treatment of other chronic, relapsing health 
problems. Except in terms of limitations on the 
length of stay and number of visits, such 
provisions are mostly the rule today. The 
committee believes that sound cost-containment 
and managed care arrangements and reliable 
performance and outcome measurements will in 
short order obviate the need for separate length-of- 
stay and dollar caps on coverage. Nonhospital 
residential and outpatient treatment delivered in 
state-certified treatment programs should be 
covered. Coverage limitations, charge schedules, 
and cost-containment incentives (e.g., copayment 
schedules) should be adjusted to reflect the 
findings of research on appropriate models, 
lengths, and costs of drug treatment—especially the 
recognition that longer residential and outpatient 
stays are strongly correlated with more beneficial 
results. 



The committee recommends that private payers 
insist that providers participate in and agree to 



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PRI V ATE CO VERA GE 



TABLE 8-2 Preferred Sites or Types of Treatment for Selected Categories of 
Drug Treatment Clients 



Inpatient/Residential 8 



Types of Service 






Needed or Client 






Characteristic 


Hospital 


Nonhospital 


Drug overdose 


P 


X 


Detoxification 


X 


S 


Rehabilitation 






High criminality 


X 


P 


Low criminality 


X 


S 


Job jeopardy only 


X 


S 


Adolescent 


X 


S 


Domiciliary (permanent 






drug-induced organic 






brain syndrome) 


X 


P 



Outpatient/Ambulatory 8 



Methadone Counseling 



X 

P 

P 
P 
P 
X 



X 



X 

p 

s 
p 
p 
p 



"P = Primary site/modality of the most appropriate treatment; 

S = secondary or less likely site for treatment (nevertheless, for some clients this may be the primary or 

preferred site owing to their specific circumstances or needs); and 
X = generally inappropriate site/modality for this type of client. 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



231 



CODA 



The best way to envision the drug problem is not as 
a fixed constellation but rather as a composite moving 
through time. As they age, each of the cohorts that 
constitute the U.S. population spreads across a broad 
continuum. At one end are lifelong abstainers, 
keeping a puzzled or horrified distance from illicit 
drugs. Partway across the continuum are light users, 
dabbling with newfound or occasional pleasures and, 
for the time being, feeling little pain. At the other 
extreme are devotees whose lives orbit around drug 
intoxication like moths worrying a flame, leaving in 
their wake not motes of dust but a trail of misery. 
Exactly who stands where on the continuum and in 
what numbers varies as behavior changes across time. 

As a further complication, each new generation of 
Americans enters a transformed world. New drug 
technologies batten on older methods; shifting 
coalitions of producers and sellers maneuver for 
markets and profits; and social responses range from 
benign neglect to bruising, large-scale mobilization of 
force. Each new generation inserts into the picture 
its own quotient of social hope, morality, anger, and 
fear. 

In this seemingly endless pharmacological and 
sociological diversity, treatment is both a rock of 
redemption and a hard place on which to secure a 
foothold. Treatment is designed to address the 
chronic, relapsing disorders of drug dependence and 
abuse, which characterize a minority of all illicit drug 
consumers but which yield probably the lion's share 
of the damaging consequences of drug consumption. 
The best treatment interventions "work"— reversing 
drug-seeking behavior, related criminal activity, and 
other dysfunctions—only partially; that is, different 
types of treatment for these aggravated and 
imperfectly understood disorders work to a greater or 
lesser degree, and each works for only some of the 
people in need. 

In short, success in treatment varies. It is not 
guaranteed and often not complete, and even if it 
were both, a major problem would still remain: most 
people who need treatment seek it only reluctantly, 
after failing at self-help, after much harm has been 
done, and after much pressure— interior and exterior- 
has been brought to bear. However, as with heart 
disease and cancer in the health domain, theft and 



assaultive behavior in the realm of violent crime, or 
homelessness and family dissolution in the area of 
social welfare, the absence of a panacea does not 
excuse society from responding with the tools at hand 
and to the best of its ability. The overall costs of 
drug problems are so high that reducing them even 
modestly is worthwhile. There is enough evidence to 
persuade this committee that a substantial proportion 
of the treatment available today is at least potentially 
capable of realizing benefits that exceed the costs of 
delivering it. Treatment seems to make sense on 
utilitarian as well as humanitarian grounds. 

There are numerous managerial complications in 
trying to raise the level of performance of the two 
tiers of treatment providers— public and private— and 
improve the different mechanisms of funding and 
control that lie behind them. If there is a brief way 
to summarize or at least place a simple label on the 
recommended approaches to these complications, it is 
this: the drug treatment system should do a better 
job of knowing itself and acting on that knowledge. 
Much that was learned in the past about the elements 
and optimal costs of effective treatment was forgotten 
or brushed aside in the early and mid-1980s in the 
zeal to cut public spending and increase private 
revenues. The mechanisms that generated useful 
knowledge were largely disassembled or never 
installed in parts of the treatment system that took 
shape during that era. 

As the 1990s begin, a different perspective is 
apparent with regard to issues of economy and 
accountability in the treatment system. There are still 
many obstacles to improving existing drug treatment, 
including inertia, vested interests, and the difficulties 
of finding, training, or reclaiming skilled and 
dedicated care givers. The weight of these obstacles 
should not be underestimated— but there are powerful 
levers to move them. Improvements are bound to 
fall into place, assuming that current financial trends 
continue, but only if the leaders of the public and 
private tiers bend their efforts to the modest but 
necessary task of making the system learn its lessons. 



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(1983) The Effectiveness and Costs of Alcoholism 
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Schasre, R. (1966) Cessation patterns among neophyte 
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Sells, S.B., ed. (1974a) Studies of the Effectiveness of 
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Sells, S.B., ed. (1974b) Studies of the Effectiveness of 
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Sells, S.B., D. Simpson, G. Joe, R. Demaree, L. 
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Sheffet, A., M. Quinones, M.A. Lavenhar, K. Doyle, 
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Siegel, R.K. (1991) Cycles of cocaine use and abuse. 
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National Institute on Drug Abuse. 



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BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS AND STAFF 



LAWRENCE S. LEWIN, chair of the Committee for the 
Substance Abuse Coverage Study, is president of the 
Lewin/ICF Health Group, a Washington-based health policy 
management consulting firm founded in 1970. He has 
directed a wide range of health policy and strategic planning 
studies for federal, state, and local governments; academic 
health centers; hospitals; nursing homes; public foundations; 
health maintenance organizations; insurance companies; and 
suppliers of services and products to the health care industry. 
He has also conducted more than 50 workshops for senior 
state and local health officials, state legislators, and business 
coalition members on a variety of health policy issues. He 
has helped develop and evaluate programs in the fields of 
aging, child development, education, and community 
development. He has chaired and staffed a variety of task 
forces, including the Task Force on Medicaid and Related 
Programs, of which he was vice chair, and gubernatorial task 
forces on health care issues in several states. He is a 
member of the Institute of Medicine. He received a B.A. 
from the Woodrow Wilson School of Public and 
International Affairs, Princeton University, and an M.B.A. 
from Harvard University. 



RAUL CAETANO is a psychiatrist and epidemiologist with 
the Alcohol Research Group, Institute of Epidemiology and 
Behavioral Medicine, Medical Research Institute of San 
Francisco at Pacific Presbyterian Medical Center, and 
associate professor in the Department of Social and 
Administrative Health Sciences, School of Public Health, 
University of California, Berkeley. He was previously the 
recipient of fellowships from the Brazilian Ministry of 
Education, the Pan American Health Organization, and the 
Medical Council on Alcoholism Research. He has been 
involved in a wide range of epidemiological studies in the 
psychiatric and substance abuse fields. His research has 
focused on the relationship between ethnicity and substance 
abuse, especially among U.S. Hispanics, and on conceptual 
issues associated with the diagnosis of alcohol dependence. 
He has been an advisor to the Pan American Health 
Organization and university and government institutions 
throughout Latin America. He is a member of the American 
College of Epidemiology, the American Public Health 
Association, and the Brazilian Psychiatric Association. He 
received an M.D. from the School of Medicine, Rio de 
Janeiro State University, and an M.P.H. and Ph.D. from the 
School of Public Health, University of California, Berkeley. 



DAVID T. COURTWRIGHT is professor and chair of the 
Department of History at the University of North Florida. 
He has also been a faculty member at the University of 
Hartford, the University of Connecticut Health Center, and 
the University of Texas School of Public Health. He has 
received fellowships from the University of Texas Medical 
Branch, the Samuel E. Ziegler Educational Foundation, and 
the National Endowment for the Humanities. He is a 
member of the American Historical Association and the 
Organization of American Historians. His publications 
include Dark Paradise: Opiate Addiction in America Before 
1940 and Addicts Who Survived: An Oral History of 
Narcotic Use in America, 1923-1965. He received a B.A. 
from the University of Kansas and a Ph.D. from Rice 
University. 



DAVID A. DEITCH, a clinical and social psychologist, is 
vice president and chief executive officer for field operations 
at Daytop Village, Inc., a nonprofit drug and alcohol 
treatment agency with facilities in New York, California, 
and Texas. He is also director of clinical and organizational 
consultation, Pacific Institute for Clinical Training, 
Education, and Consultation, Berkeley, California. He was 
previously executive director and cofounder of Daytop 
Village, senior vice president and chief clinical officer of 
Phoenix House Foundation, and chief of substance abuse 
services, University of California, San Francisco. He has 
also been a clinical faculty member in departments of 
psychiatry at the University of California, San Diego; the 
University of Chicago; and Temple University. He was 
chairman of the White House Task Force on Prevention, a 
consultant to the Presidential Commission for the Study of 
Crime and Juvenile Delinquency and the National 
Commission on Marijuana and Drug Abuse, and a member 
of the Pennsylvania Governor's Council on Alcohol and 
Drug Abuse. He received the state of California award for 
outstanding contributions in the drug abuse field. He 
received his M.S. and Ph.D. from the Wright Institute, 
Berkeley, California. 



DOUGLAS A. FRASER is professor of labor studies at 
Wayne State University. He was the Jerry Wurf Fellow and 
Lecturer at the John F. Kennedy School of Government, 
Harvard University. He is retired from the United Auto 
Workers, where he served as vice president and president. 
First appointed to the staff of the UAW in 1947, he 



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concentrated much of his energy on negotiating and 
implementing employee benefit programs. He was 
responsible for the union's early retirement program, 
restrictions on compulsory overtime, a comprehensive health 
and safety program, dental care benefits, reduced work time, 
and improvements in the cost-of-living allowance formula. 
He has served as cochair of the Michigan Governor's 
Commission on Jobs and Economic Development and as a 
member of the board of trustees of the Aspen Institute for 
Humanistic Studies and the Executive Committee of the 
Leadership Conference on Civil Rights and as a member of 
the board of governors of the United Way. 



a study of substance abuse prevention for high-risk youth and 
a methodological study of client self-reports after treatment, 
among other drug research studies at the Research Triangle 
Institute. He was previously at the Survey Research Center, 
University of Michigan. He is a member of the American 
Association for Public Opinion Research, American 
Psychological Association, American Public Health 
Association, American Society of Criminology, American 
Sociological Association, and the American Statistical 
Association. He received a B.A. from Ohio University, a 
Ph.D. from the University of Michigan, and an M.B.A. 
from the Fuqua School of Business, Duke University. 



JAMES G. HAUGHTON is medical director of the Martin 
Luther King, Jr./Charles R. Drew Medical Center of the Los 
Angeles County Department of Health Services. After 
serving in leading public health positions with the New York 
City Health and Welfare Departments, he served for nine 
years as the executive director for the Health and Hospitals 
Governing Commission in Chicago and subsequently as 
director of the Department of Health and Human Services, 
City of Houston. He is currently a member of the advisory 
board of the Robert Wood Johnson Foundation AIDS health 
service programs and the board of directors of the Alan 
Guttmacher Institute. He has received awards from the 
National Association of Health Services Executives, the 
March of Dimes, and the Los Angeles Board of Supervisors. 
He is a fellow of the American College of Preventive 
Medicine and the American Public Health Association, and 
a member of the American Medical Association, National 
Medical Association, Southern Medical Association, Texas 
Medical Association, United States Conference of Human 
Services Officials, and the United States Conference of Local 
Health Officials. He is a member of the Institute of 
Medicine. He received a B.A. from Pacific Union College, 
an M.D. from Loma Linda University, and an M.P.H. from 
Columbia University School of Public Health and 
Administrative Medicine. 



ROBERT L. HUBBARD is a social psychologist and 
program director for alcohol and drug abuse research in the 
Center for Social Research and Policy Analysis, Research 
Triangle Institute, North Carolina. He was principal 
investigator for the Treatment Outcome Prospective Study 
follow-up of a large multi-city sample of drug treatment 
clients, and he is the lead author of Drug Abuse Treatment. 
He has completed studies on adult and teenage drug use 
epidemiology; the relationships among drug use, 
employment, and crime; assessment of vocational services in 
drug treatment programs; and management styles and 
occupational programs in industry. He is currently directing 



JAMES D. ISBISTER is president of Pharmavene, Inc. 
His career in government from 1962 to 1977 included 
service as the administrator of the Alcohol, Drug Abuse, and 
Mental Health Administration. He has been vice president 
of the Orkand Corporation, associate director for 
management of the International Communication Agency, 
senior vice president of the Blue Cross and Blue Shield 
Association, and president of Combined Technologies, Inc. 
He has received the William A. Jump Foundation Award for 
exemplary achievement in public administration, the Arthur 
S. Flemming Award, and numerous other commendations. 
He received a B.A. from the University of Michigan and an 
M.A. from George Washington University. 



HERBERT D. KLEBER is on leave as professor of 
psychiatry at Yale University School of Medicine where he 
is founding director of the Substance Abuse Treatment Unit 
at the Connecticut Mental Health Center. He is also director 
of Yale's Center for Opioid and Cocaine Abuse Treatment 
Research and chief executive officer of APT Foundation, 
Inc. He served on the Governor's Drug Advisory Council 
(Connecticut) and cochaired the Mayor's Task Force on 
Drugs (New Haven). He has received the American 
Psychiatric Association Gold Award, the Foundations Fund 
Award for Research, and the Founders Award of the 
American Academy of Psychiatrists in Alcoholism and 
Addiction (AAPAA). He previously served on the national 
advisory councils of the National Institute on Drug Abuse 
and the National Institute of Mental Health. He is a fellow 
of the American Psychiatric Association and the American 
College of Neuropsychopharmacology, a member of the 
American Medical Association, and a founding member of 
AAPAA. He received a B.A. from Dartmouth College and 
an M.D. from Jefferson Medical College, serving a 
psychiatric residency at Yale. In August 1989 he was 
confirmed by the U.S. Senate as deputy director for demand 
reduction in the Office of National Drug Control Policy. 



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SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1 



JUDITH R. LAVE is professor of health economics at the 
Graduate School of Public Health, University of Pittsburgh. 
She has also taught economics and urban affairs at Carnegie 
Mellon University and was director of the Office of 
Research, Health Care Financing Administration, U.S. 
Department of Health and Human Services. She is a 
member of the American Economic Association, the 
American Public Health Association, and the Association for 
Health Services Research, which she served as president. 
She is a member of the Institute of Medicine. She received 
a B.A. from Queen's University and an M.A. and Ph.D. 
from Harvard University. 



DAVID J. MACTAS, a certified addictions specialist and 
social worker, is president of Marathon, Inc., a nonprofit 
drug and alcohol treatment and research agency based in 
Providence, Rhode Island. He was previously on the staff 
of the Morris J. Bernstein Institute, St. Vincent's Medical 
Center, and the Vera Institute of Justice, all in New York 
City, and he served as assistant commissioner of the New 
York City Addiction Services Agency. He has taught at 
Rhode Island College and New England Institute of 
Technology. He served as president of Therapeutic 
Communities of America and is a board member of the 
World Federation of Therapeutic Communities. He received 
a B.A. from City College of New York and an M.A. from 
the New School for Social Research. 



DONALD J. McCONNELL is executive director of the 
Connecticut Alcohol and Drug Abuse Commission. He has 
previously been a priest with the Archdiocese of Newark; an 
educational consultant with the Institutes for Rural 
Education, Santiago, Chile; director of Latin American 
Studies at Seton Hall University; director of education and 
training, State of New Jersey Drug Abuse Project; and 
director of addiction services, Connecticut Department of 
Corrections. He was the recipient of the National 
Association of State Alcohol and Drug Abuse Directors' 
award for outstanding leadership and dedication, the Alcohol 
and Drug Problems Association award for outstanding 
achievement for an individual, the Nyswander/Dole award 
for contributions to the field of methadone maintenance, and 
the Connecticut Hispanic Addiction Commission award for 
dedication to the recovery of Latino substance abusers. He 
is a member of the Alcohol and Drug Problems Association, 
the Advisory Council on AIDS of the National Institute on 
Drug Abuse, and the National Association of State Alcohol 
and Drug Abuse Directors, which he has served as president. 
He received a B.A. from Seton Hall University, an M.Div. 
from Immaculate Conception Seminary, and two M.A. 



degrees and a Ph.D. candidate certificate from the University 
of Wisconsin at Madison. 

JOHN H. MOXLEY III is vice president and partner at 
Kom/ Ferry International, where he conducts nationwide 
searches for physician executives sought by organizations in 
the private and public sectors. Before joining Kom/Ferry, 
he had his own consulting practice focusing on organizational 
issues in health care. His prior experience includes positions 
as senior vice president of American Medical International, 
Inc.; assistant secretary of defense for health affairs in the 
Department of Defense; vice chancellor and dean of 
medicine at the University of California, San Diego; dean of 
the University of Maryland School of Medicine; and assistant 
to the dean of Harvard Medical School. In 1984, he served 
as director of Polyclinic Health Services for the XXIII 
Olympics. He has served on the board of trustees of the 
American Hospital Association and chaired the scientific 
board and served on the governing council of the California 
Medical Association. He currently serves on the board of 
the National Fund for Medical Education and the Henry M. 
Jackson Foundation for the Advancement of Military 
Medicine. He is board -certified in internal medicine and is 
a fellow of the American College of Physicians and a 
distinguished fellow of the American College of Physician 
Executives. He is a member of the Association of American 
Medical Colleges, the Society of Medical Administrators, 
and the American Society of Clinical Oncology. He is a 
member of the Institute of Medicine. He received an A.B. 
from Williams College and an M.D. from the University of 
Colorado. 



PETER S. O'DONNELL is a partner and cofounder of the 
KEREN Group, a health care management and marketing 
firm based in Princeton, New Jersey. He has previously 
been the president and chief executive officer of a regional 
managed care health plan with more than 20,000 members 
and 1,400 physicians under contract. Prior to that he was 
senior vice president of ALTA Health Strategies, Inc., a 
major third-party administrator of health benefits, where he 
developed and implemented utilization review programs and 
related managed care programs. He was previously director 
of employee benefits for the RCA Corporation; a consultant 
for the Wm. Mercer Company, a national health benefits 
consulting firm; senior health advisor to the governor of 
Florida, staff associate with the National Governors' 
Association; and a member of the staff of the Advisory 
Commission on Intergovernmental Relations. He is a 
member of the editorial board of Managed Care Outlook and 
serves on the board of the Alpha Center and the Foundation 
for Health Services Research. He received a B.A. from the 



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Pennsylvania State University and an M.A. from Rutgers 
University. 

MARK V. PAULY is professor of health care systems and 
public management at the Wharton School, director of 
research of the Leonard Davis Institute of Health Economics, 
and professor of economics at the University of 
Pennsylvania. His major interests are public finance, 
collective decision making, insurance regulation, and medical 
economics. He serves on the health advisory board of the 
American Enterprise Institute, where he has been an adjunct 
scholar, and he has also been a board member of the 
Association for Health Services Research. He has held 
fellowships at the International Institute of Management 
(Berlin) and the International Institute for Applied Systems 
Analysis (Vienna). He has been a faculty research fellow at 
the National Bureau of Economic Research, professor of 
economics at Northwestern University, and a research 
associate with the U.S. Public Health Service. He is a 
member of the American Economic Association and the 
Association for Health Services Research. He is a member 
of the Institute of Medicine. He received an A.B. from 
Xavier University, an M.A. from the University of 
Delaware, and a Ph.D. from the University of Virginia. 



HAROLD A. RICHMAN is director of Chapin Hall Center 
for Children and Hermon Dunlap Smith Professor in the 
School of Social Service Administration, University of 
Chicago. His earlier positions at the University of Chicago 
include dean of the School of Social Service Administration, 
founding chairman of the Committee on Public Policy 
Studies, and codirector of the children's policy research 
project. He was previously a White House fellow and 
special assistant to the secretary of labor. He is currently on 
the board of the University of Chicago Laboratory Schools 
and is a member of the executive management committee, 
National Opinion Research Center. He chairs the research 
advisory committee on youth of the Lilly Endowment, Inc., 
and the Children's Program Committee of the Edna 
McConnell Clark Foundation; he is also a member of 
numerous nonprofit boards and advisory committees. He 
received an A.B. from Harvard College and a Ph.D. in 
social welfare policy from the University of Chicago. 



MAXINE L. STITZER is associate professor of behavioral 
biology in the Department of Psychiatry and Behavioral 
Sciences, Johns Hopkins University School of Medicine, and 
associate director of the drug abuse treatment research unit 
at Francis Scott Key Medical Center. She has been active in 
drug abuse research with areas of specialization in human 
behavioral pharmacology and substance abuse treatment 
evaluation. She serves as editorial consultant for several 



scientific journals and was previously a member of the 
clinical/behavioral research review committee of the National 
Institute on Drug Abuse. She is a fellow of the American 
Psychological Association and a member of the Behavioral 
Pharmacology Society, American Public Health Association, 
and Society for Behavioral Medicine. She received a B.A. 
from the University of California, Berkeley, and an M.S. 
and Ph.D. from the University of Michigan. 



DEAN R. GERSTEIN, a sociologist, is a study director at 
the Institute of Medicine and National Research Council of 
the National Academy of Sciences, where his earlier studies 
include Alcohol and Public Policy: Beyond the Shadow of 
Prohibition, Commonalities in Substance Abuse and Habitual 
Behavior, Guidelines for Studies on Substance Abuse 
Treatment, and The Behavioral and Social Sciences: 
Achievements and Opportunities. He has done research on 
addiction careers, drug treatment programs, alcohol and 
highway crashes, smoking and mortality, and the 
development of social theory and held editorial positions with 
Contemporary Drug Problems and Sociological Theory. 
Previously, he was at the University of California, Los 
Angeles, the University of California, San Diego, and the 
Veterans Administration Medical Center, La Jolla. He is a 
member of the American Sociological Association, the 
American Public Health Association, the Kettil Bruun 
Society for Sociological and Epidemiological Research on 
Alcohol, and the Alcohol and Drug Study Group of the 
American Anthropological Association. He received a B.A. 
from Reed College and a Ph.D. from Harvard University. 



HENRICK J. HARWOOD, an economist, served as 
associate study director for the Substance Abuse Coverage 
Study. Prior to joining the staff of the Institute of Medicine, 
he was at the Research Triangle Institute in North Carolina, 
where he was the principal author of Economic Costs of 
Alcohol and Drug Abuse and Mental Illness— 1980 and 
contributed the economic analyses used in the Department of 
Health and Human Services' report to Congress, Toward a 
National Plan to Combat Alcohol Abuse and Alcoholism. He 
has done research on the impact of alcohol and drug 
consumption on productivity in the work force, the crime- 
related costs and benefits of different modalities of drug 
treatment, and the provision of employment services and 
vocational services in drug treatment programs. He has held 
adjunct faculty appointments at Erasmus University in 
Rotterdam, the Netherlands, and Duke University. He 
received a B.A. from Stetson University and performed 
graduate studies in economics at the University of North 
Carolina, Chapel Hill. In December 1989 he accepted the 
position of senior policy analyst in the Office of National 
Drug Control Policy. 



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ACKNOWLEDGMENTS 



During the Substance Abuse Coverage Study, many 
individuals shared ideas and information with the study 
committee. The most important contributions in this 
respect were of two sorts: participation in two symposia 
organized by the committee in Washington, D.C., on 
June 1, 1988, and in Irvine, California, on October 4, 
1988, and hosting of site visits by committee members 
and staff in six states during the intervening months. 



The symposia gave the committee an opportunity to hear 
from and question closely a selection of knowledgeable 
individuals involved with drug treatment programs in a 
variety of roles such as clinical services, research, 
administration, third-party funding, and referral. These 
events gave the committee opportunities to hear not only 
individual presentations but also the participants' 
counterpoints to each other's and to the committee's 
tentative points of view. These exchanges breathed life 
into the committee's images of the treatment system, 
and committee members are grateful to all of the 
symposium participants for taking part in these 
important formative events. 



Present at the Washington symposium were the 
following: 

M. Douglas Anglin, Drug Abuse Research Group, 

University of California, Los Angeles 
Patricia Armocida, Blue Cross/Blue Shield Association, 
Chicago, Illinois 
John C. Ball, Addiction Research Center, Baltimore, 

Maryland 
Lee Grutchfield, Human Resource Development, 

Continental Airlines , Houston, Texas 
Norman Hoffmann, Chemical Addiction! Abuse 

Treatment Outcome Registry, The Ramsey Clinic, 

St. Paul, Minnesota 
Don Jones, Consulting and Continuing Education 

Department, Hazelden Foundation, Minneapolis, 

Minnesota 
Jill Klobucar, Human Affairs International, Arlington, 

Virginia 
Richard J. Russo, New Jersey State Department of Health, 

Trenton 



Steven Sharfstein, Sheppard and Enoch Pratt Hospital, 

Baltimore, Maryland 
Bruce Wander Els, Milliman and Robertson, Radnor, 

Pennsylvania 



Participants in the Irvine symposium were: 

M. Douglas Anglin, Drug Abuse Research Group, 

University of California, Los Angeles 
Gary Atkins, Employee Assistance Programs, Lockheed 

Missile and Space, Sunnyvale, California 
Sherry Conrad, Department of Alcohol and Drug 

Programs, State of California, Sacramento 
Michael Q. Ford, National Association of Addiction 

Treatment Providers, Irvine, California 
Uwe Gunnerson, Azure Acres Chemical Dependency 

Rehabilitation Center, Sebastopol, California 
Y-Ing Hser, Drug Abuse Research Group, University of 

California, Los Angeles 
Ed Liebson, Blue Cross of California, Oakland 
Anthony Radcliffe, Kaiser -Permanente Medical 

Center, Fontana, California 
Galen Rogers, Preferred Management, San Diego, CA 
William Smith, Phoenix House, Santa Anna, California 
Irma Strantz, Department of Health Services, County of Los 

Angeles, California 
Susan Zepeda, Orange County Health Services 

Administration, Santa Anna, California 



The committee's hosts during site visits to cities across 
the country offered a degree of cooperation, hospitality, 
and candor in response to the committee's questions that 
made a deep and lasting impression. The hosts received 
assurance that no comments or observations would be 
attributed to specific individuals or organizations and 
that individual anonymity would be full preserved. 
Many of those visited indicated that such assurances 
were not a precondition for their cooperation; 
nevertheless, these guarantees have been observed in the 
report, and the committee feels that it is important to 
uphold them here. Therefore, names of the many 
individual hosts in whose debt the study remains are not 
included here. 



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SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1 



The committee wishes, however, at least to signal the 
extent of their contributions by expressing its thanks to 
each of the following organizations for permitting access 
to their staff and facilities: 

AIDS Outreach Project, Portland, Oregon 

Allegheny County Mental Health, Mental Retardation, and 

Drug Abuse Program, Pittsburgh, Pennsylvania 
Bank of America, San Francisco, California 
Bay Area Treatment Services, Berkeley, California 
Beth Israel Medical Center, New York, New York 
The City of New York Office of Municipal Labor Relations 
Comprehensive Care Corporation, Irvine, California 
Comprehensive Options for Drug Abusers, Portland, 

Oregon 
Cornerstone Correctional Treatment Program, Salem, 

Oregon 
Daytop Village, New York, New York 
Gateway Program, St. Louis, Missouri 
Hooper Memorial Center, Central City Concern, 

Portland, Oregon 
Hyland Center, St. Anthony Hospital, St. Louis, Missouri 
Ielase Institute of Forensic Psychiatry, Pittsburgh, 

Pennsylvania 
International Association of Machinists and Aerospace 

Workers, District 100, Miami, Florida 
ITT Corporation, New York, New York 
Jewish Hospital Chemical Dependency Program, 

Washington University at St. Louis, Missouri 
Martin Luther King/Charles A. Drew Medical Center, Los 

Angeles, California 
Metro Dade County Office of Rehabilitative Services, 

Miami, Florida 
Metro Dade County Office of Substance Abuse Control, 

Miami, Florida 
Missouri Department of Mental Health, Division of 

Alcohol and Drugs, St. Louis 
Multnomah County Alcohol and Drug Program, Portland, 

Oregon 
Narcotic and Drug Research, Inc. , New York, New York 
Narcotics Addiction Services Council, St. Louis, Missouri 
New York State Division of Substance Abuse Services, 

Albany 
PBA, Inc., The Second Step, Pittsburgh, Pennsylvania 
Project for Community Recovery, Portland, Oregon 
Project Rediscovery, Pittsburgh, Pennsylvania 
Providence Medical Center, Portland, Oregon 
Office of the State Attorney, Eleventh Judicial Circuit of 

Florida, Miami 
Outside-In, Portland, Oregon 
Regional Drug Initiative, Portland, Oregon 
St. Francis Hospital, Pittsburgh, Pennsylvania 
Spectrum Programs, Miami, Florida 
Southwestern Bell, St. Louis, Missouri 



State of Oregon Office of Alcohol and Drug Abuse 

Programs, Salem 
TASC of Oregon, Portland 

Up Front Drug Information Center, Miami, Florida 
Walden House, San Francisco, California 
Watts Health Foundation, Los Angeles, California 
Western Health Services, Portland, Oregon 

A final thanks is due to individuals who responded to 
the committee's questions in writing or with substantive 
materials that might not otherwise have become known 
to the committee. These correspondents include: 

Leslie Acoca, Novato, California; 
Karl Bernstein, Silver Spring, Maryland; 
Sheila Blume, Amityville, New York; 
Frank R. Burger, Nashville, Tennessee; 
Frank N. Coogan, Milwaukee, Wisconsin; 
Thomas J. Doherty, Washington, D.C.; 
Julie Donalson, Sacramento, California; 
P. Joseph Frawley, Santa Barbara, California; 
Cherry Lowman, New York, New York; 
Judith Ovisher, Arlington, Virginia; 
Max A. Schneider, Orange, California; 
James W. Smith, Santa Barbara, California; 
Jack R. Slaberg, Nashville, Tennessee; and 
Emanuel M. Steindler, New York, New York. 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



Index 



Abstinence 

as centra! goal of drug treatment, 6, 97 

full, partial, and nonrecovery, 96, 97 

goals of chemical dependency programs, 132, 133 

individual drug history, 44 
Accreditation, Medicaid and drug treatment program, 18 
Acquired immune deficiency syndrome (AIDS) 

Anti-Drug Abuse Act of 1988, 39 

epidemic and national drug policy, 2 

goals of drug treatment, 7, 81 

health costs of drug problem, 74 

Medicaid coverage, 212 

methadone programs, 10 

transmission by injection, 49 n.2 
Addiction Severity Index, 84 
Admissions, residential treatment 

committee recommendations on optimal private coverage 

provisions, 22 

elimination of waiting lists, 1 84 

utilization management and review, 19, 198 
Adolescents 

additional policy questions, 26, 27 

age of drug use onset, 49, 50 

aggregate need for drug treatment, 5 

estimating extent of need for drug treatment, 59 

patterns of drug consumption, 3 

research recommendations, 14, 153 
Adults 

aggregate need for drug treatment, 5 

arrests for drug crimes, 87 

committee findings and recommendations, 26 

estimating extent of need for drug treatment, 59 

patterns of drug consumption, 3 

treatment research statistics, 14 
Aftercare, chemical dependency programs, 133 
Age 

aggregate need for drug treatment, 5 

individual drug history, 49 

patterns of drug consumption, 3 

treatment research statistics, 14 
Aid to Families with Dependent Children 

(AFDC), 19, 153, 197, 211 
Alabama, state drug coverage mandates, 227 
Alcohol and alcoholism 

Addiction Severity Index, 84 

chemical dependency programs, 11, 215 

cost -effectiveness of treatment, 222 

employee assistance programs, 92, 224, 225 

employers and private coverage decisions, 220, 221 

extension of treatment capacity to drug treatment, 171 

partial legality, 44 



pregnant women, 65 

private insurance coverage, 217 

recovery and relapse compared to heroin, 53 

state mandates regarding treatment coverage, 225 n.5 

therapeutic communities, 123 

trends in provider characteristics, 162, 165 

Alcohol, Drug Abuse, and Mental Health Administration 

(ADAMHA) 

block grant administration, 193 

emergency appropriation for FY 1 990, 1 70 

health services research programs, 151 

strategic planning for drug treatment, 188 

trends in federal funding, 170 
Alcoholics Anonymous 

chemical dependency programs, 11, 37, 132, 133, 148 

drug treatment programs, 102 
Amantadine, 135 
Ambivalence, 

client incentives and motivation, 178 

spectrum of recovery, 95-99 
Anslinger, Harry, 34 
Anti-Drug Abuse Act of 1986 

call for independent study of substance abuse treatment 
coverage, 1, 24 

emphasis on enforcement and interdiction, 39 

federal support of research, 149 

federal support of treatment, 74, 156 n.1, 170, 193 

TASC programs, 89 
Anti-Drug Abuse Act of 1988 

federal policy and treatment, 39, 170, 194 

federal support of research, 149 

TASC programs, 89 

waiting list reduction, 1 84 
Arkansas, state drug coverage mandates, 227 
Arrests, law enforcement and drug crimes, 87 
Attitudes 

full, partial, and nonrecovery, 97 

normative, 44 
Attrition, client, 95, 96 



B 



Barbiturates, detoxification, 135 n.21 

Benefits (see Cost/benefit analysis, Insurance) 

Bennett, William, 39 

Block grants 

federal role in 1980s, 193, 194 
management and federal funding, 195 
reduction in federal funding, 156 n.1 
research on women, 153 
sources of treatment dollars, 166, 168 



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Blue Cross/Blue Shield, 215, 217, 221-223, 226 
Boot campts, effectiveness of correctional treatment 

programs, 12, 142, 144 
Brain 

effects of opiates, 104 

effects of psychoactive drugs, 46 
Bromocriptine, 135 
Budget (see Financing) 
Buprenorphine, 135, 211 
Bureau of Narcotics and Dangerous Drugs, 36 



California 

Civil Addict Program, 140, 142 

Medicaid and AIDS, 212 

Medicaid and drug treatment, 209, 210 

methadone maintenance programs, 108, 109, 115 
CareUnit system, 1 35 
Certification 

performance and public support, 20, 197, 199 
Chemical Abuse/Addiction Treatment Outcome Registry 

(CATOR), 93, 134, 161 
Chemical dependency programs 

average daily charges, 226, n.7 

description of modality, 132-134 

effectiveness of , 11, 134, 135 

private coverage and effectiveness, 215 

research on treatment effectiveness, 14, 141, 145, 222 

research recommendations, 152 

rise of modern treatment, 34, 35 

state-mandated coverage, 226 

summary of committee findings, 148 

variations in effectiveness, 135 
Child care, mothers and drug treatment, 153, 186 
Children (see also Adolescents, Pregnant Women) 

age of drug use onset, 49 

external costs of drug abuse, 183 

patterns of drug consumption, 3 

women and therapeutic communities, 153 
Civil Addict Program 

(CAP), 109, 111, 130, 140 142, 143, 218 
Civil rights 

concern for drug-dependent individuals, 83 

economic status of clients, 96 
Class 

chemical dependency program clients, 37 

criminal and medical views of drug addiction, 33 

employee assistance programs, 92 

opium addiction and medical idea, 31, 32 
Client-Oriented Data Acquisition Process 

(CODAP), 126, 136, 161, 191, 193 
Client, drug treatment 

chemical dependency programs and therapeutic 
communities compared, 134, 135 

individual goals, 97-99 

parties involved in treatment, 82 

public and private tiers, 161 

trends in numbers and provider characteristics, 162-165 
Clinical trials, 

research on major modalities of drug treatment, 13 n. 2 

detoxification, 135, 136 

drug sequencing, 50 



emergency room and medical examiner cases, 55, 56 

employee assistance programs, 93 

federal policy emphasis on enforcement, 39 

history of use, 47-49 

improvement of public coverage, 185 

methadone programs, 9 

need for expansion of public tier, 172 

normative attitudes, 44 

patterns of drug consumption, 3 

patterns of drug treatment motivation, 85 n.2 

positive tests among arrestee, 72 

pregnant women, 65 

research recommendations, 14, 152, 153 

state prison inmates, 60, 61 

therapeutic communities, 10, 116, 123 

urinalysis, 71 
Collective bargaining, employer-sponsored health 

insurance, 214 
Colorado, Medicaid funding of drug treatment, 211 
Community-based treatment 

Alcoholics Anonymous methods, 102 n.2 

criminal justice system referrals, 7, 91 

goals of drug treatment, 83 

origins of, 35, 36, 101 
Community Mental Health Centers Act, 37 
Consumer price index (CPI), 166 n.2 
Contracts, direct program financing of public tier, 18 
Copayments, treatment needs and cost concerns, 220 
Cornerstone programs, effectiveness of correctional treatment 

programs, 139, 140 
Correctional treatment programs 

effectiveness, 137, 140-145 

summary of committee findings, 148, 149 

trends in client numbers, 162 
Cost/benefit analysis 

effectiveness of drug treatment programs, 1 2 

methadone treatment, 113, 114, 146 

outpatient nonmethadone programs, 132, 147 

therapeutic communities, 147 
Costs 

balancing concerns with treatment needs, 182, 183 

baseline comparison values, 201, 202 

committee recommendations for private coverage, 230 

comprehensive strategy option, 204-206 

core strategy option, 189, 202-204 

estimation for drug problems, 72-74 

external costs and logic of mandating private insurance 
coverage of drug treatment, 216 

external costs and public intervention, 177-179 

goals of drug treatment, 98 

intermediate strategy option, 206-208 

management and health care issues, 215 

offsets and private coverage of drug treatment, 220-221 

private and public tiers, 171 

private coverage and drug treatment, 228 

private coverage and health benefits, 221-225 

quantification of societal, 66, 67 

state mandates and private coverage, 226 

utilization management, 19, 197 
Counseling and counselors 

improvement of public coverage, 185, 186 

methadone maintenance, 106, 107 

private versus public tiers, 161 



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NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



INDEX 



Courts, criminal justice 

prison overcrowding and referrals to treatment, 92 

referrals to private programs, 86 

referrals to treatment, 87, 89 
Courtwright, David, 25, 30, 82, 83, 86, 103 
Crime 

effectiveness of Stay'n Out program, 137-140 

estimating the cost of drug problems, 72, 73 

methadone clients, 9, 107, 116 

outpatient nonmethadone programs, 1 32 

reduction as goal of drug problems, 7, 83, 89 

societal costs of drug abuse, 66, 67 

type and probable need for treatment, 71 

therapeutic communities, 123, 129 
Criminal idea 

classic era of narcotics control, 34 

drug policy, 2, 33, 34, 39, 40, 171 

evolution of governmental roles, 37-39 

external costs and public intervention, 177 
Criminal justice system (see also Law enforcement, Parole, 

Probation) 

Addiction Severity Index, 84 

additional policy questions, 26 

agencies as parties in drug treatment, 83 

comprehensive strategy option, 204-206 

estimating extent of need for treatment, 59-61, 67 

estimating need for treatment among arrestees, 71-72 

federal drug policy, 170 

goals of drug treatment, 81, 86-91, 99 

health services research, 151 

implications of involvement in admissions to drug 
programs, 86 

inducing more clients to accept treatment, 188 

reasons for seeking treatment, 86 



Data and data systems 

federal role in 1980s, 193, 194 

health services research, 151, 152 

performance standards, 195 

private coverage and sources, 214 

utilization management, 19, 20, 198 
Daytop Village 

early success stories, 119 

therapeutic community approach to treatment, 36 
Deaths, heroin recovery and relapse, 53 
Dederich, Charles, 36 
Defense, Department of (DoD), 209 n.5 
Demography 

populations of different modalities, 101 

therapeutic community population, 116 

treatment research statistics, 14 
Demonstration grants, health services research, 152 
Depression, 

emotional, 45, 84, 99, 104, 131, 135, 153, 217, 222 
Depression, Great, 34 
Desipramine hydrochloride, 135 
Deterrence 

prisons and criminological thought, 34 
Detoxification 

cross-dependence, 104 

effectiveness, 11, 135, 136 



indications for hospital-based inpatient, 20, 198 

recovery and relapse, 4 

summary of committee findings, 148 
Diagnosis, individual need for drug treatment, 5, 50-52 
Diagnostic and Statistical Manual of Mental Disorders 

(DSM-III-R), 50-52, 56, 69, 
Dole, Vincent, 35, 36, 104, 107, 108, 112, 113 
Drug abuse and dependence 

complexity of problem and estimation of need for 
treatment, 67-69 

diagnostic criteria, 50-52 

diagnosis and detoxification, 135 n.20 

individual drug history, 42-52 

quantification of societal costs, 66, 67 
Drug Abuse Forecasting (DUF) System, 71, 72, 151 
Drug Abuse Reporting Program(DARP) 

evaluation of effectiveness of OPNMs, 131, 132 

research on effectiveness of drug treatment, 7, 8, 101, 151 

study of effectiveness of therapeutic communities, 1 16-130 
Drug Abuse Treatment Outcome Study (DATOS), 8, 101, 152 
Drug Abuse Warning Network (DAWN) 

cocaine consumption, 49 

data systems and research, 151 
Drug consumption 

estimation of need for treatment, 67, 68 

goals of drug treatment, 97 

individual drug history, 42-44 

level of use and criminality, 90 

methadone dosage levels, 112 

patterns and need for drug treatment, 3, 41 

use, abuse, and dependence stages, 44 
"Drug czar," 37, 39 

Drug dependence (see Drug abuse and dependence) 
Drug-Free Workplace Act of 1988, 93 
Drug history, individual 

age of onset and drug sequencing, 49, 50 

learning and drug experience, 46, 47 

model and overview of individual, 42-44 

social environment, 47, 49 
Drug screening programs 

availability to workers, 92 n.4 

employers and goals of treatment, 93, 94 
Drug sequencing, individual drug history, 49, 50 
Drug testing, employee 

libertarian ideas, 32 

private treatment programs and goals of drug treatment, 83 
Drug trade 

crime control resources, 73 

homicide, 72 
Drug treatment (see also Chemical dependency programs, 

Correctional treatment programs, Detoxification, Methadone 

maintenance, Private tier, Public tier, Therapeutic 

communities) 

balancing needs and cost concerns, 182, 183 

changing nature of drug problems, 232 

determining individual need, 5, 50-52 

diverse interests and goals, 82, 83 

effectiveness, 7-14, 22, 100-154 

employers and goals, 92-95 

erosion of after 1976, 170 

estimating extent of need for, 5, 6, 54-67 

estimating need for among arrestee, 71, 72 

estimating need for in criminal justice populations, 54-59 



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SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1 



estimating need for in homeless population, 65 
estimating need for in household population, 69-71 
evaluation of effectiveness and untreated recovery rate, 54 
goals, 6, 7, 99 

growth of national system, 162-170 
health insurance cost outlays, 221 
improvement as priority of public coverage, 185, 186 
modeling future treatment needs and effects, 208 
overall tendencies of effectiveness, 101, 102 
as principle of public intervention, 181, 182 
reasons for seeking, 84-86 
recommendations for research on services and 
methods, 150-153 
research on effectiveness, 101, 102 
rise of modern, 34-39 

role of in federal anti-drug abuse strategy, 170 
state Medicaid coverage for specific services, 211, 212 
two-tiered system, 15 
DuPont, Robert, 38 



criminal view of drug problem, 33 

goals of drug treatment, 98 

parties involved in drug treatment, 82 

reasons for seeking treatment, 87 

therapeutic communities, 1 1 8 
Federal Employee Benefits Health Plan, 219 
Financing 

amounts needed to meet priority objectives, 201 

differences between private and public tiers, 156 

private coverage, 20-22, 214-232 

public care, 15-20, 176-213 

sources of treatment dollars, 1 66 

trends in federal funding, 170 

trends in funding base, 1 65 
Flupenthixol decanoate, 135 
Food and Drug Administration 

Dole-Nyswander model of methadone maintenance, 36 

LAAM, 105 n.6 
Function impairments, recovery process, 4 



Economics (see also Indigence; Poverty) 

client assets and motivation for recovery, 96 

quantification of social costs, 67, 68 
Education 

chemical dependency programs, 133, 134 

goals of drug treatment, 98 
Effectiveness (see Drug treatment) 
Elderly, concern about abuse and dependence, 49 
Emergency rooms, estimating extent of need for treatment, 56 
Employee assistance programs (EAPs) 

defining goals of treatment, 92, 93 

employee drug testing, 94 

managed care system, 224, 225 
Employee Retirement Income Security Act (ERISA), 226, 227 
Employers 

drug screening programs, 93 

extent and nature of insurance coverage for drug 
treatment, 214, 220 

federal government and drug treatment coverage, 219, 220 

goals of drug treatment, 92-95, 99 

parties involved in drug treatment, 83 

private companies and drug treatment coverage, 217, 218 

reasons for seeking treatment, 86 

state and local government and drug treatment 
coverage, 218, 219 
Employment 

Addiction Severity Index, 84 

aggregate need for drug treatment, 5 

cost/benefit ratio of methadone maintenance, 113 

cost/benefit ratio of outpatient nonmethadone 
programs, 132 

goals of drug treatment, 7, 98 

therapeutic communities and treatment retention, 123 



Facilities, improvement of public coverage, 186 

Families 

Addiction Severity Index, 84 
chemical dependency programs, 133 



Gatekeepers 

employee assistance program staff, 224 

utilization management, 19, 197 
Gaudenzia House, 129 
Goals 

criminal justice agencies, 86-92 

detoxification, 136 

diverse interests, 82, 83 

drug treatment, 6, 7, 99 

employers, 92-95 

full, partial, and nonrecovery from drug problems, 96, 97 

methadone maintenance, 103 

operational for programs, 81 

and priorities of public coverage, 16, 17 

reasons for seeking treatment, 84-86 

setting realistic, 97-99 
Government, federal 

crime control resources, 73 

employees and drug treatment coverage, 219, 220 

financing of public tier, 15, 18, 19, 

libertarian ideology, 31, 32 

Medicaid and matching dollars, 209, 210 

national drug policy, 2, 3 

role in the 1990s, 194-196, 201 

support for drug research, 149 

trends in funding, 170 
Government, local 

crime control resources, 73 

employees and drug treatment coverage, 218 

sources of treatment dollars, 166 
Government, state (see also States, and individual states) 

crime control resources, 73 

employees and drug treatment coverage, 218 

financing of public tier, 15, 18, 19, 166 

responsibility for public tier in 1980s, 193, 201 

role in the 1990s, 194-196 
Grants (see also Block grants) 

direct program financing of public tier, 17 

matching and maintenance-of-effort requirements, 18, 197 
Great Britain, methadone maintenance, 103 
"Great Society," 2 



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INDEX 



H 



Harrison Act of 1914, 34 
Hazelden Foundation, 37, 134 n. 19 
Hearth (see also Public health) 

Addiction Severity Index, 84 

estimating costs of drug problems, 74 

methadone clients, 9 
Health Maintenance Organizations (HMOs), 220, 226 n.6 
Health services 

cost offsets, 221 

research and treatment systems, 13, 14 

research recommendations, 151, 152 
Heart infections, transmission by injection, 49 n.2 
Hepatitis, transmission by injection, 49 n.2 
Heroin 

detoxification and relapse, 104, 136 

Dole-Nyswander research on methadone 

maintenance, 35, 36 

effects compared to methadone, 105, 106 

emergency room and medical examiner cases, 56 

literature on dependence and recovery, 53, 54 

literature on patterns of drug treatment motivation, 85 n.2 

Nixon administration "War on Drugs," 38 

research and problem of noncompliance, 119 n.14 

state prison inmates, 61 

therapeutic communities, 10, 116, 123 
Homeless, estimating extent of need for treatment, 65, 66 
Homicide, drug trafficking, 72 

Hong Kong, study of methadone Maintenance, 108 n.8 
Hospitals 

chemical dependency programs, 11, 148 

committee recommendations on optimal private coverage 
provisions, 21 

cost control and utilization management, 19 

drug detoxification, 11, 136, 148 

optimal private coverage provisions, 229 

prescription of methadone, 105 

trends in drug treatment client numbers, 162 

utilization management and public tier, 198 
Household population, estimating extent of need for 

treatment, 56, 59, 69-71 
Human immunodeficiency virus (HIV) 

(see also Acquired immune deficiency syndrome) 

methadone programs, 10 



I 



Ideas 

character of governing, 28, 29 

drug treatment policy, 2, 3, 37 

rise of modern drug treatment, 34-37 

spectrum of about drugs, 29-34 
Illinois Drug Abuse Program, 37 

Incapacitation, prisons and criminological thought, 34 
Incentives 

external costs and public intervention, 178 

private providers and efficiency, 222, 223 

staff performance, 1 86 
Income 

constraints and public support of treatment, 179, 181 

employee productivity losses, 73, 74 

estimating extent of need for drug treatment, 59 



as index of external costs, 1 82 

private tier and insurance coverage, 216 

sensitivity of drug abusers to price of treatment, 216 
Indigence, committee estimates of and public 

coverage, 16, 181, 200 
Infants (see Pregnant women) 
Injection, transmission of disease, 49 n.2 
Insurance, health (see also Financing, Medicaid, Private 

coverage. Public coverage) 

employer-sponsored and unions, 214 

and income constraints, 179, 181 

mandates, 215, 225-228 
International Statistical Classification of Diseases, Injuries, and 

Causes of Death (ICD-10), 50-52, 56, 59 



Jaffe, Jerome, 37, 38 

Jails, compared to prison, 60 n.5 

Job applicants, drug screening programs, 93 

Johnson Institute, 37 

Journal of the American Medical Association, 35 

Justice Assistance Act of 1984, 89 



Law enforcement (see also Crime, Criminal justice system) 

additional policy questions, 27 

arrests for drug crimes, 87 

crime control resources, 73 

societal costs of drug abuse, 66, 67 
Learning 

drug consumption behavior, 50 

individual drug history, 46-47 
Legalization, illicit drugs, 208 
Legislation (see also specific acts: 

Anti-Drug Abuse, Drug-Free 

Workplace, Employee Retirement 

Income Security, Harrison, Justice 

Assistance, Narcotic Addiction 

Rehabilitation, Omnibus Budget Reconciliation) 

early anti-drug, 32 

federal and Medicaid, 196, 212 

federal anti-drug and expansion of public tier, 1 6 

state-mandated private coverage, 21, 215, 225-229 
Levo-alpha-acctylmethadyl (LAAM), 105 n.6, 119n.14 
Libertarian ideas 

drug policy, 2, 31, 32, 39, 40 

influence on nation's collective thinking, 178 



M 



Managed care 

employee assistance program personnel, 225 

health insurance and cost containment, 223, 224 
Marijuana 

drug sequencing, 50 

emergency room reports, 56 

employee assistance programs, 93 

normative attitudes, 44 

patterns of drug consumption, 3 

positive tests among arrestee, 71, 72 



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state prison inmates, 60, 61 

urinalysis, 71, 72 
Marketing, chemical dependency programs, 14, 152 
Maryland, state-mandated drug treatment coverage, 226 
Medicaid 

federal contribution, 1 66 

federal legislation and drug treatment needs, 196, 197 

public tier funding of treatment 

services, 18, 19, 201, 208-213 

transitional steps toward the year 2000, 196 
Medical idea 

classic era of narcotics control, 34 

drug policy, 2, 32-34, 39, 40 

evolution of governmental roles, 37-39 

influence on nation's collective thinking, 177 

private treatment programs and goals of drug treatment, 83 
Medical price index (MPI), 165, 166 n.2 
Medicare 

nursing home care and Medicaid, 220 

population served and treatment needs, 209 

public coverage and income constraints, 179, 181 
Men 

aggregate need for drug treatment, 5 

estimating extent of need for drug treatment, 59 

married and reasons for seeking treatment, 85 

treatment research statistics, 14 
Meperidine, 103 n.3 
Methadone 

compared to naltrexone and LAAM, 119 n.14 

effects compared to heroin, 105, 106 

opiate detoxification, 1 35 

types of narcotic analgesics, 103 n.3 
Methadone maintenance 

characteristics of long-term clients, 122 

Civil Addict Program supervision, 142 

clinical behavioral strategy, 105, 106 

compared to outpatient nonmenthadone 
programs, 10, 131, 132 

compared to therapeutic communities, 129 

cost/benefit ratio, 12, 113 

criminal justice system and reasons for seeking 
treatment, 86 

description of modality, 102, 103 

effectiveness, 8-10, 107, 109, 115 

excess capacity, 161, 162 

expansion of private tier, 171 

goals of treatment, 103 

incentives to continue treatment, 179 

need for expansion of public tier, 171, 172 

negative beliefs among public and policy makers, 103 n.4 

prevalence of repeat admissions, 85 

research on expenditures and effectiveness, 12, 13 

research on treatment effectiveness, 145 

rise in modern treatment, 34, 35, 100 

significant private demand not subsidized by private 
insurance reimbursements, 216 

substitution, 104, 105 

summary of committee finding, 145, 146 

trends in client numbers, 1 62 

variations is effectiveness, 11, 12, 109 
Modeling, future treatment needs and effects, 208 
Mothers (see also Pregnant women) 

additional policy questions, 26, 27 



priorities of public coverage, 186 
research recommendations, 14, 153 
Motivations, client 

ambivalence and spectrum of recovery, 96 
full, partial, and nonrecovery, 96, 97 
goals of drug treatment, 6, 7, 81 
reasons for seeking drug treatment, 84-86 



N 



Naltrexone 

compared with methadone, 119 n.14 

incentives to continue treatment, 1 79 
Narcotic Addiction Rehabilitation Act (NARA) of 1966, 36, 37 
National Academy of Sciences, 24, 74 
National Association of State Alcohol and Drug Abuse Directors 

(NASADAD), 184, 189,202 
National Drug and Alcoholism Treatment Utilization Survey 

(NDATUS) 

baseline comparison values, 201 

data on client numbers and provider characteristics, 1 62 

data on provider insurance receipts, 114 

health insurance and cost of drug treatment, 221 

public and private tiers, 156, 170-172 

women and special services, 153 
National Drug Control Strategy (September 1988), 39, 56, 188 
National Forum on the Future of Children and Families, 27 
National Household Survey of Drug Abuse (1988), 69 
National Institute of Justice, 56, 71, 80, 144, 151 
National Institute on Drug Abuse (NIDA) 

evolution of government roles, 38 

health services research programs, 151 

household survey data and estimation of extent of need for 
treatment, 56, 59 

research on treatment services and methods, 150 

research recommended on adolescents, pregnant women, 
and mothers, 14 

research responsibilities, 153 

sponsor of report, 24 

transfer of authority from SAODAP, 193 

transition of role to research and educational functions, 1 93 

zoning and "not in my backyard" problem, 1 52 
New York 

Dole-Nyswander research and methadone treatment 
programs, 36 

early trials of methadone maintenance, 107-109, 112, 113 

Medicaid policies, 212, 213 

study of heroin recovery and relapse, 53 
Nicotine, partial legality, 44 

Nixon, Richard, administration and drug policy, 2, 36, 38 
Normative attitudes, individual drug history, 44 
North Dakota, state drug coverage mandates, 227 
"Not in my backyard" (NIMBY) problem, 152 
Nursing homes. Medicare and Medicaid, 220 
Nyswander, Marie, 35, 36 



Office of Economic Opportunity, 37 

Office of National Drug Control Policy 

establishment and federal drug policy, 39, 194 
inconsistencies among federal programs, 19 
strategic planning for drug treatment, 188 



258 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



INDEX 



Office of Personnel Management, 217, 219 
Office of Treatment Improvement, 151, 188 
Omnibus Budget Reconciliation Act (OBRA), 192, 193 
Opiates (see also Buprenorphine, Heroin, LAAM, Methadone, 

Naltrexone) 

addiction in nineteenth century, 31 

effect, on brain, 104, 105 

pharmacological agents and detoxification, 135 

pharmacological properties of, 104 

positive tests among arrestee, 71, 72 

urinalysis, 71 
Opium 

early anti-drug legislation, 31 

nineteenth-century addiction and medical idea, 31 

types of narcotic analgesics, 103 n.3 
Oregon, state drug coverage mandates, 228 
Outpatient nonmethadone programs (OPNMs) 

cost/benefit ratio, 13, 132 

cost effectiveness compared to therapeutic 
communities, 129 

description of modality, 131 

effectiveness of drug treatment, 10, 131 

prison treatment programs, 12 

private coverage and effectiveness data, 215 

research on treatment effectiveness, 12, 13, 145 

rise in modern treatment, 36, 100 

summary of committee finding, 147 

trends in client numbers, 162 

variations in effectiveness, 1 32 
Oxford House, 102 



Parole (see also Civil Addict Program, Criminal justice system) 

community-based treatment programs, 7 

estimating extent of need for treatment, 61 

implications of criminal justice involvement in admissions to 
drug treatment, 86 

reasons for seeking treatment, 85 

state prison inmates and revocation, 60 n.6 
Pennsylvania, Medicaid and drug treatment, 212, 213 
Performance 

certification and public support, 20 

committee recommendations on optimal private coverage 
provisions, 21, 22, 230 

states and data systems, 195, 196 

utilization management, 197 
Phillips, Mary Dana, 25 
Phoenix House, 122, 124, 137 

Pleasure seeking, methadone of effective analgesic, 105 
Policy, national drug 

effect of alternative scenarios on need for treatment, 208 

fundamental questions, 176 

ideas governing, 2, 3, 39, 40, 

questions for additional study, 1, 2, 26, 27 

rise of modern drug treatment, 34-39 

rule of simple ideas, 28, 29 

spending patterns, 1 66 

spectrum of ideas about drugs, 29, 34 
Population studies, estimating extent of need for treatment, 54 
Poverty (see also Indigence) 

external costs and treatment needs, 183 
Preferred provider organizations (PPOs), 223 



Pregnant women (see also Children, Mothers) 

comprehensive strategy option, 205 

core strategy option, 203 

estimating extent of need for treatment, 65, 66, 186 

Medicaid coverage, 212 

research recommendations, 14, 153 
Presidential Commission on the Human Immunodeficiency Virus 

Epidemic (1988), 56 
Price, sensitivity of drug abusers to cost of 

treatment, 216, 217 
Prison-hospitals 

classic era of narcotics control, 34 

rise of modern treatment, 34, 35 
Prisons 

compared to jails, 60 n.5 

effectiveness of drug treatment, 12 

external costs and public intervention, 177, 178 

motivations for treatment, 96 

overcrowding and criminal justice referrals to 
treatment, 7, 92 

populations and estimating extent of need for 
treatment, 59-61 

referrals to treatment, 89-91 
Private coverage 

committee recommendations, 228-231 

cost containment of health benefits, 221-225, 227 

extent, 217-221 

logic of mandating coverage of drug treatment, 216 

state mandates, 225-228 
Private tier 

clients compared to public tier, 161 

defined, 155 

drug treatment coverage, 20-22, 217-221 

drug treatment supply system, 170-172 

excess capacity, 161, 171-172 

expansion in 1980s, 171 

financing, 156 

goals of drug treatment, 83 

overview, 214 

ownership of programs, 1 65 

ratio of drug treatment expenditures, 156 

referrals from criminal justice system, 86 

sources of treatment dollars, 1 5 
Probation (see also Criminal justice system) 

community-based treatment programs, 7 

estimating extent of need for treatment, 61 

implications of criminal justice involvement in admissions to 
drug treatment, 86 

outpatient nonmethadone treatment, 131 

prisons and criminological thought, 34 

reasons for seeking treatment, 86 
Productivity 

employers and drug treatment, 94, 220 

estimating costs of drug problems, 73, 74 

goals of drug treatment, 81 

societal costs of drug abuse, 67 
Profit, growth of drug treatment industry in 1980s, 216 
Psychoactive drugs (see also Heroin; Methadone; Opiates) 

effects on brain, 46 

federal and state codes, 44 

medical and social uses and fundamental ideas about 
drugs, 28 

outpatient nonmethadone programs, 131 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES, No. 2 



259 



SUBSTANCE ABUSE COVERAGE STUDY. VOLUME 1 



Psychotherapy, clinical rigor, 95 
Public health 

goals of drug treatment, 7, 8 

policy role of treatment, 39, 40 

societal costs of drug abuse, 67 

street sales of methadone, 103 n.5 
Public Health Service, 34, 35, 153 
Public coverage 

adequacy of present means for managing, 176 

committee recommendations, 196-198 

federal and state roles, 191-196 

Medicaid, 196, 197, 209-212 

principles of coverage, 176-183 

priorities, 183-188 

strategy options, 188-191, 201-208 

veterans, 199 
Public tier 

ambulatory treatment, 1 65 

capacity and need for expansion, 171 

clients compared to private tier, 161 

criminal justice referrals, 86 

defined, 155 

drug treatment supply system, 1 70 

erosion after 1976, 170, 171 

excess capacity, 161 

financing, 15, 18, 19 

goals and priorities, 16, 17 

ratio of drug treatment expenditures, 161 

selective expansion and resource intensity, 1 6 



Race/ethnicity 

criminal and medical views of drug addiction, 33, 34 

libertarian view of drug use, 31 

therapeutic community clients, 1 17 n. 12 
Reagan, Ronald 

administration and drug policy, 39 

California and Civil Addict Program, 140 
Recidivism 

drug consumption and criminality, 90 

length of imprisonment and drug involvement, 90 
Recommendations (see Policy, national drug; Private coverage; 

Public coverage; Research, needs and priorities) 
Recovery 

ambivalence and spectrum of, 95-99 

drug dependence, 4, 5 

full, partial, and nonrecovery, 96, 97 

goals of drug treatment, 81, 99 

individual drug history, 53, 54 
Rehabilitation, prisons and criminological thought, 34 
Reimburses, third-party and drug treatment, 82 
Relapse 

detoxification, 11, 104 

drug dependence, 3, 4 

individual drug history, 53, 54 
Remission, term compared to recovery, 53 n.3 
Research 

animal models, 46 

character of nonexperimental evaluations, 118, 119 

on effectiveness and expenditures for major treatment 
modalities, 12, 13 

on effectiveness of drug treatment, 145 



experimental evaluation of effectiveness of therapeutic 

communities, 119, 122 
needs and priorities for treatment services and 

methods, 13, 14, 149-153 
optimal private coverage provisions, 22 
Retention 

therapeutic communities, 147 
treatment effectiveness, 146 n.26 
Rice, Dorothy, 67, 74 



Self-recovery, relapse, 4, 5 
Sentences, criminal justice 

law enforcement and drug crimes, 87 

varying lengths and prison populations, 60 n.6 
Shock incarceration (SI), effectiveness of correctional treatment 

programs, 12, 142 
Social change, fundamental ideas about drugs, 28 
Social services 

improvement of public coverage, 185 

outpatient nonmethadone programs, 131 
Society 

ethical position on income constraints, 179 

external costs and private coverage, 216 

external costs and public intervention, 1 78 
Socioeconomic environment 

additional policy questions, 27 

drug dependence, 3 

individual drug history, 47, 49 

recovery and relapse, 4, 53 
Special Action Office for Drug Abuse Prevention 

(SAODAP), 3, 8, 39, 191-195, 197 
Staff 

chemical dependency programs and therapeutic 
communities compared, 133 

composition of in 1982 NDATUS, 166 n.2 

differential effectiveness of treatment programs, 1 6 

improvement of public coverage, 185, 186 

requirements of public tier programs, 161 

variations in treatment effectiveness, 113, 126, 144 
States (see also Government, state) 

drug problems among prison inmates, 60, 61 n.7 

mandates of private coverage of drug 
treatment, 21, 215, 225-228 

medical/criminal ideas and evolution of governmental 
roles, 37-39 

use of Medicaid to fund treatment, 209 
Statistics, sample size and standard error, 71 
Stay'n Out, effectiveness of correctional treatment 

programs, 137, 140 
Stereotypes 

individual drug history, 42 

pleasure user and ethnicity, 31 
Supplemental Security Income, 19, 197, 210 
Supreme Court, criminal idea and drug policy formation, 34 
Sweden, methadone maintenance, 108 
Synanon 

early success stories, 119 

therapeutic community approach to treatment, 36, 100 



260 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



INDEX 



Technology, libertarian view of drug use, 31 
Therapeutic communities 

compared to chemical dependency programs, 133 

compared to outpatient nonmethadone 
programs, 10, 131, 132 

cost/benefit ratio, 12, 126 

description of modality, 116 

effectiveness of drug treatment, 10, 118, 129 

origins and development, 100 

prison treatment programs, 140 

research on expenditures and effectiveness, 12 

research on treatment effectiveness, 145 

rise in modern treatment, 36 

summary of committee findings, 146, 147 

variations in effectiveness, 126 
Tobacco 

partial legality, 44 

pregnant women, 65 
Treatment Alternatives to Street Crime (TASC), 87, 89, 94 
Treatment Outcome Prospective Study (TOPS) 

cost/benefit analyses, 115 

effectiveness of drug treatment, 25, 101, 152 

effectiveness of OPNMs, 131, 132 

effectiveness of therapeutic communities, 122, 123, 129 

veterans as clients, 199 

TASC referrals, 87-89 

variations in effectiveness of methadone maintenance 
programs, 109, 112 

veterans and drug treatment programs, 199 



Women (see also Mothers; Pregnant women) 

opiate addiction in nineteenth century, 32 

reasons for seeking treatment, 85 

research recommendations, 1 53 

self-esteem, and treatment, 153 

Stay'n Out program, 140 

therapeutic communities and graduation rates, 123 n.17 
World War II, decline in drug problem, 34, 35 



Zoning, drug treatment programs, 152 



u 



Unemployment 

aggregate need for drug treatment, 5 

estimating extent of need for drug treatment, 59 

goals of drug treatment, 7 
Unions, employer-sponsored health insurance, 214 
Urban neighborhoods, goals of drug treatment, 83 
Urinalysis 

clinical rigor, 95, 96 

estimating need for treatment among arrestee, 71, 72 
Utilization management 

optimal private coverage provisions, public financing of drug 
treatment, 22 

public financing of drug treatment, 19, 20 

public intervention in the 1990s, 197-199 



Veterans, as special case of public coverage, 17, 199-201 
Veterans Affairs, Department of, 199, 200, 209 n.5 
Vietnam War, 199 



w 



Waiting lists 

elimination as priority of public coverage, 184, 185 
reduction and core strategy option, 1 89 

Willmar State Hospital, 37 

Withdrawal, methadone and symptoms of heroin, 106 



NIDA DRUG ABUSE SERVICES RESEARCH SERIES. No. 2 



261 



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